Family Practice Vol. 16, No. 3, 312-315
© Oxford University Press 1999
Present and future management of asthma and COPD: proceedings from WONCA 1998
Dept of General Practice and Social Medicine, Nijmegen University, The Netherlands,
a The Kenton Bridge Medical Centre, Kenton, Middlesex, UK,
b Bridgetown Health Centre, Bridgetown, Killinick, Ireland,
c School of Health, Policy and Practice, University of East Anglia, Norwich,
d Woodbrook Medical Centre, Loughborough, Leicestershire,
e James Fisher Medical Centre, Bournemouth, UK,
f Dept of General Practice, University of Maastricht, The Netherlands.
Thoonen BPA, van Schayck CP, van Weel C, Levy ML, Spelman R, Price D, Ryan D, Bellamy D, van Grunsven P, Cloosterman S, van den Boom G, Gorgels W and Schönberger H. Present and future management of asthma and COPD: proceedings from WONCA 1998. Family Practice 1999; 16: 312–315.
Received 24 November 1998; Accepted 28 January 1999.
Abstract
On 15 June 1998, a workshop on asthma and chronic obstructive pulmonary disease (COPD) was held at the WONCA conference in Dublin. Based on the current guidelines for diagnosis and treatment of asthma and COPD, new developments and present and future research projects were discussed. Based on these guidelines and the research findings, new developments were positioned. The final conclusion of this workshop was that there is a need to continue exchanging ideas at an international level. So an initiative to start a Scientific Group of Primary Care Research within the European Respiratory Society has been taken.
Keywords. Asthma, COPD, guidelines, primary care, research.
Introduction
On 15 June 1998, a workshop on asthma and chronic obstructive pulmonary disease (COPD) was held at the WONCA conference in Dublin. The aim of the workshop was to discuss present and future developments in the fields of asthma and COPD in general practice. This workshop was a joint venture of the British and Irish GPs in Asthma Groups (GPIAG) and the Asthma/COPD in General Practice Research Group of the University of Nijmegen, The Netherlands.
Recent advances in asthma
An increasing number of guidelines on the diagnosis and treatment of asthma and COPD exists.1,3–8 Before applying any one of those guidelines, an accurate diagnosis is essential. Based on data from the DIMCA study,9 CP van Schayck (University of Nijmegen/Maastricht, The Netherlands) showed that much asthma and COPD still remain undiagnosed (20–60%), and that the prevalance of these diseases is increasing despite improved treatment. The DIMCA study also shows that undiagnosed patients respond positively to inhaled steroids and could be treated and diagnosed as asthmatics. As there are as yet no validated primary preventive measures, the importance of improving early diagnosis was emphasized. Detection of undiagnosed asthma patients is a major challenge for the future. The DIMCA study showed that screening the annual decline in forced expiratory volume in one second (FEV1) in subjects with chronic cough and shortness of breath may be an effective strategy for tracing undiagnosed asthma or COPD. Whether this approach is cost-effective has yet to be established.
M Levy (GPIAG, UK) discussed several methods in use to administer inhaled medication for acute asthma. He concluded that spacers may be useful in general practice, but scientific evidence is lacking, as present studies investigating the usefulness of spacers are not yet applicable to general practice. Another option discussed by M Levy was the usefulness of pulse-oximetry to monitor the patient during the treatment of an acute asthma attack. Pulse-oximetry, combined with an oxygen-driven nebulizer, may be an efficient way to treat acute asthma attacks and prevent sudden, life-threatening hypoxaemias.
The role of long-acting beta-2 agonists was reviewed by D Ryan (GPIAG, UK). Prior to their clinical use, fears had been expresseed10 about the regular use of beta-2 agonists, as this appeared to destabilize asthma. Two randomized controlled trials in mild to moderate11 and moderate to severe12 asthma demonstrated their efficacy when compared with doubling up the dose of inhaled steroids. The measures in which superiority was observed were improved morning and evening peak-flow measurements, reduction in rescue use of short-acting beta-2 agonists, and reduction in morning and evening symptom scores. An increase in asthma exacerbations was not observed in the group using salmeterol.
A further study13 using a double-blind crossover design demonstrated that when patients used a long-acting beta-2 agonist in conjunction with a strict self-management plan, a reduction of inhaled steroid dose of 17% could be achieved. Finally, a year-long study14 examined the effects of adding an inhaled beta-2 agonist to both lower and higher doses of inhaled steroids in patients with persisting symptoms over a period of 1 year. It found that the addition of long-acting beta-2 agonists improved both symptoms and pulmonary function without any increase in the exacerbation rate. In summary, long-acting beta-2 agonists are a useful and effective adjunct to treatment in patients whose asthma is not controlled under low-dose inhaled corticosteroids.
Currently, exact positioning for the Leukotriene Antagonist is not entirely clear, but current evidence was reviewed by Dr D Price (GPIAG, UK) along with a suggested positioning. Leukotriene antagonists clearly improve all clinical end-points in asthma, including FEV1, independent of beta agonists and, at least to some extent, inhaled steroids. This would suggest that leukotriene pathways have not been fully treated by our more traditional asthma therapies. It was recommended that they may be useful for patients failing to respond fully to inhaled steroids and beta-agonist therapy. When prescribing leukotriene antagonists, a trial of between 1 week and 1 month should verify whether patients respond to this class of therapy.
At the end of this session, P van Grunsven (University of Nijmegen, The Netherlands) presented data from the DIMCA study on aspects of compliance. The success of any treatment depends on the compliance of patients. Compliance for anti-inflammatory treatment was approximately 70% of the prescribed dose during the study period, and no predictors for compliance could be identified.15,16 Most frequently, self-reported reasons for non-compliance were the absence of symptoms, experiencing (or fearing) side-effects and not having the time to take the medication. If treatment of early asthma and early COPD is shown to be effective, then non-compliance to inhaled steroids may be a major obstacle. Therefore, compliance should regularly be assessed during follow-up visits. Repeat education may be an important tool to enhance compliance.
Management of asthma and COPD
The second session focused of the actual usage of the present guidelines. The BTS issued their revised guidelines on the management of asthma1 and COPD8 in 1997; one of the changes was the advice to use self-management programmes. Scientific evidence of the beneficial effects of these programmes is building up, but questions remain on what plans to use and which patients may profit from them most. B Thoonen (University of Nijmegen, The Netherlands) demonstrated that self-management plans revolve around the increased sharing of responsibilities between GP and patient, and introduced the concept of self-managed education. Self-managed education keeps interests of both GP and patient in mind, and thus decreases the specific information needs of patients. As this approach to self-management of asthma is still under examination, further results will probably follow in the near future.
R Spelman (GPIAG, Ireland) discussed the usage of current guidelines by GPs. He showed that almost 50% of Irish GPs use asthma guidelines, often locally adjusted national guidelines. As these local guidelines take into account the accessibility of local resources and prescribed medication, they are often a more pragmatic translation of the common guidelines. On the basis of the NHBLI/ Gina guidelines,2 Spelman demonstrated that choosing the proper treatment for patients is not always a matter of gradually stepping up. First, a thorough severity assessment should be done, and subsequently treatment is started on the appropriate severity step. Starting with higher doses (a step-down regimen) may reduce the overall cumulative dosage of (inhaled) steroids, while this may add to the risk of overtreating some patients during certain periods.
C van Weel (University of Nijmegen, The Netherlands) demonstrated that most of the statements in various asthma guidelines are also applicable to children. However, there are some major differences. One of the specific actions for asthmatic children is the monitoring of growth and development. This provides both information of the severity of asthma and of possible growth inhibition due to prescribed (anti-inflammatory) medication. There are specific difficulties when diagnosing asthma in children. In contrast with adults, it often takes an observation period of up to 3 years to diagnose childhood asthma. During these 3 years it is difficult to give proper advice. Even when asthma is diagnosed, there are some specific therapeutic aspects which differ from the adult guidelines. In order to avoid side-effects of anti-inflammatory treatment, it may be best to prescribe a trial of therapy based on symptoms. During the process of diagnosing and treating asthma, it is also important to pay attention to the family situation. Barriers to effective treatment may very well be not only at the level of the patients but at the level of the parents as well. D Bellamy (GPIAG, UK) discussed the present BTS COPD guidelines, which were recently published in Thorax.7 COPD is a very common disease that causes considerable morbidity, poor quality of life and 26 000 deaths per year in the UK. The diagnosis and management of COPD is still a neglected area, with many primary care physicians merely telling patients to stop smoking and suggesting that nothing else can be done for them. Smoking is certainly the most important cause of COPD, and smoking cessation offers the most effective means of preventing disease progression. However, only 20% of the smokers develop COPD, and at present the co-factors that make this group susceptible have not been identified. The guidelines propose a more holistic view of treatment. Therapeutic options include bronchodilators (the cornerstone of symptomatic improvement in breathlessness, wheezing and exercise), corticosteroids, rehabilitation training, long-term oxygen and surgery. It is also important to address social problems and treat the secondary depression that often accompanies severe COPD. Immunization against influenza may help to prevent infective exacerbations. According to the BTS guidelines, goals of the management of COPD are: early and accurate diagnosis of COPD, optimizing symptom control, preventing deterioration of lung function and complications, and improving the quality of life. The use of spirometry by GPs is strongly encouraged to diagnose and assess the severity of COPD. Patients with moderate or severe COPD should undergo a steroid reversibility study to determine whether inhaled steroids will be beneficial in long-term management. Long-acting bronchodilators improve symptoms and the quality of life, but more studies are needed to fully evaluate their use.
Asthma and COPD research in primary care
In the third and final session, results from recent research projects and some upcoming projects were presented.
S Cloosterman (University of Nijmegen, The Netherlands) discussed two recent placebo-controlled studies on the effects of house dust-mite avoidance measures on asthma symptoms, FEV1 and peak flow in allergic patients with and without asthma.17 She concluded that house-dust-mite-impermeable mattress covers were capable of reducing the amount of house dust-mite allergen. These reductions were followed by improvements in morning peak flow and symptom scores in patients with no diagnosed asthma. In patients with asthma, bronchial hyperresponsiveness and FEV1 did not change significantly. Allergic patients without asthma showed an earlier and greater response than allergic patients with asthma. Therefore, house dust-mite avoidance measures seem to be more useful and effective in early stages of asthma.18,19 The underlying mechanism of this phenomenon is still unclear and requires further research.
The PREVASK study, a new research project to assess whether early prenatally started interventions may lead to preventive effects on the development of asthma in infants was presented by H Schönberger (University of Maastricht, The Netherlands). He presented data from general practice which suggest a genetic predisposition for developing asthma. Many of the relevant risk factors are often already known to the GP and are easily recordable. Exposure to these risk factors may lead to the expression of genetic predispositions and might well be preventable. In the PREVASK study, the effects of reduction of exposure will be evaluated over the next few years.
G van den Boom (University of Nijmegen, The Netherlands) presented a cost-effectiveness study based on the DIMCA project.20 Screening of subjects from the open population during a maximum of 12 months traced approximately 20% of the open population with undiagnosed asthma or COPD. The costs per detected case were US$564, which is relatively little compared with other screening programmes. Treatment was initiated for these patients and the effects and costs will be evaluated in the near future in a cost–benefit analysis. Screening of a population followed by treatment of newly diagnosed patients will always incur extra expense. It is important to weigh up these costs against the gains in health and quality of life—a so-called cost-effectiveness study—to support medical decisions and health policies. One of the recent developments in the treatment of COPD patients is treatment with N-acetyl-cysteine as an anti-oxidant drug. The effectiveness of this therapy on relevant parameters such as a decline in FEV1, exacerbation rates and quality of life is still unknown. W Gorgels (University of Nijmegen, The Netherlands) demonstrated the supposed anti-oxidant effects of N-acetylcysteine and the design of the recently started COOPT study. This 3-year study compares the efficacy of N-acetylcysteine and fluticasone diproprionate in a placebo-controlled design among 600 COPD patients recruited from at least 30 general practices.
The final speaker of this workshop was M Levy, who presented the effects of training practice nurses in an asthma training centre. Training practice nurses improved the organization of asthma management and increased confidence in patients in the advices given. Practices with trained nurses used self-management plans more frequently. One of the negative effects, however, was that compliance to follow up visits was dramatically reduced. Although the data presented came from a relatively small study, the results did show relevant changes in the organization and management of asthma in general practice, so M Levy concluded that the effects of training nurses on practice management needed further addressing.
Conclusion
This international initiative to draw up an inventory of present and future developments in the management of asthma and COPD was of great value. There proved to be a clear concensus on the place of some new developments in the treatment of asthma and COPD in general practice, such as the use of long-acting bronchodilators and leucotriene antagonists. It was concluded that priorities of research in these fields are the detection of unknown patients, further placement of non-steroid anti-inflammatory treatment and the effects of self-management. As all guidelines promote the usage of spirometry, further research on the implementation of this technique in general practice needs to be promoted.
Although relevant differences in the various national guidelines are present, comparison of these guidelines showed that there is an increasing convergence in ideas about how chronic airway diseases should be treated. Asthma and COPD have a high prevalence in general practice, and the majority of patients are treated by the GP. Therefore, it is important that current guidelines also take into account general-practice-based evidence. The present and future research projects presented in this workshop clearly showed that research in general practice can and will provide this scientific evidence. In order to prevent redundancy, it is important that these research efforts are well co-ordinated at an international level. The final conclusion of this workshop therefore was that there is a need to continue exchanging ideas at an international level. The WONCA conference offers a good opportunity for this purpose. Another possibility is to form a Scientific Group of Primary Care Research within the European Respiratory Society, as this also provides an easy interface between primary and sec-ondary respiratory care. An initiative to start such a Scientific Group has been taken already, and we would welcome any national group of GPs or individuals to join this initiative.
For more information you could contact:
Prof. Onno van Schayck
Department of General Practice, University of Nijmegen
PO Box 9101
6500 HB Nijmegen, The Netherlands
Telephone: +31-243613315
Fax: +31-243617084
E-mail: O.vanSchayck{at}hsv.kun.nl
or
Dr Mark Levy
The Kenton Bridge Medical Centre
155–175 Kenton Road
Kenton, Middlesex HA3 0YX, UK
Telephone: +44-181-9076989
Fax: +44-181-9076003
E-mail: marklevy{at}gpiag-asthma.org
Website: http://www.gpiag-asthma.org/asthma/marklevy/marklevy.htm
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