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The University of Southampton

Experts urge change in asthma management

Published: 1 December 2008

The need for an urgent change in asthma management is advocated this week by a group of respiratory specialists, patient representatives, GPs and paediatricians from across Europe and North America.

Writing in the December issue of the European Respiratory Journal (ERJ), the group, which includes Professor Stephen Holgate, Medical Research Council Professor of Immunopharmacology at the University of Southampton, identifies deficiencies in a range of areas in relation to asthma, including: diagnosis, recognition of the disease nature, asthma control, set-up of clinical trials, treatment of asthmatic children, asthma research and environmental conditions.

The group also calls for a concerted effort from policymakers, regulators, health professionals, industry and patients, to remedy the significant disparities in asthma management practices between and within European countries, to ensure better outcomes for European asthma patients.

The prevalence of asthma has increased dramatically over the last 20 years and around 180,000 deaths annually are attributable to asthma worldwide. It is particularly common in industrialized countries.

The article in the ERJ highlights the Finnish Asthma Programme as a best-practice example of asthma management. The authors say the programme demonstrates that early diagnosis, personalised treatment and guided self-management, combined with patient education and reductions in tobacco smoking and exposure to environmental risk factors, can improve patients' asthma whilst reducing overall costs.

Stephen Holgate comments: "The Finnish Asthma Programme is a compelling example of what can be achieved when all parties cooperate. I hope it will find as many 'copycats' as possible."

Susanna Palkonen from the European Federation of Airways Diseases Patients' Associations (EFA) adds: "Patients have to be empowered to manage their disease and have a say in decisions on their care."

John Haughney from the International Primary Care Respiratory Group (IPCRG) concludes: "Currently, a lot of patients have asthma which is insufficiently controlled. The education and involvement of GPs is crucial if we want to improve this situation."

The article validates key findings from the Brussels Declaration, launched in June 2007, which outlined how and when changes need to be made to the way that asthma is managed in the EU to ensure optimum treatment for all patients.

Notes for editors

The article: 'The Brussels Declaration: the need for change in asthma management' is published in the European Respiratory Journal.
The article underlines the following seven determinants of change necessary for better management of asthma:


1. Diagnosis:
Over-reliance on lung function as a diagnostic test can be misleading, say the authors, and may fail to provide adequate insight into the impact of asthma on daily living. Other tests, including methacholine challenge and sputum eosinophil counting, have been shown to be useful for discriminating between asthma and other diseases, they say.

2. Disease nature:
In the past, asthma was considered to be a simple disease involving reversible airflow obstruction that could be treated with bronchodilators. It is now clear, say the authors, that the disease is much more complex, involving multiple inflammatory cascades and infiltration of inflammatory cells into the airways. These inflammatory changes do not appear to be confined to the lower airways but also include the nose. Asthma and allergic rhinitis affect the same tissues, involve common inflammatory mechanisms, cells and mediators and are frequently found together.

3. Asthma control:
According to the Asthma Insights and Reality in Europe (AIRE) Study only 5.4 per cent of asthma patients meet the GINA criteria for asthma control. To address poor control, physicians need to focus on controlling asthma and not just adherence to treatment regimens, the article says. Patients require routine individualised evaluation that can identify psychological and lifestyle factors contributing to insufficient control and poor outcomes. Patient education focusing on the benefits and risks of treatment is crucial; so is professional education that emphasizes the importance of engaging with the patient.

4. Clinical trials:
Results from clinical trials, upon which guidelines are based, differ significantly depending on the outcome measure examined, say the authors.
Furthermore, the patients included in clinical trials for asthma can differ from patients in real practice (for example, patients with co-morbidities such as allergic rhinitis, or smokers are usually excluded), leading to a statistical bias in outcomes. As a result, the current evidence base used in asthma management guidelines is far from ideal for recommending asthma therapy in the real-world setting, they add.
Every clinical trial should be judged by its ability to translate to a larger real-life population, say the authors. Since current clinical trials are limited in this respect, there is a clear need for real-world pragmatic and effective trials that include typical patients seen by physicians in daily clinical practice. Regulators, in return, have a responsibility to include latest evidence in their guidance to companies which research and develop asthma medication.

5. Paediatric asthma:
The dramatic increase in the prevalence of asthma is largely due to an increase in childhood asthma, the authors stress. In Europe, asthma is now a major chronic illness of childhood, with up to 20 per cent of children affected and asthma being the most common reason for hospitalising children.
Current treatment guidelines do not contain enough information on paediatric asthma, they say, and the information that is provided is frequently not being followed. There is a clear need for clinical trials that examine the efficacy and safety of asthma medications in children, differentiating between pre-school children, school-age children and adolescents.

6. Research gaps:
There is still no cure for asthma and there have been few new treatment innovations. In particular, there are currently no medications that can alter the natural history of the disease. Work is needed to identify the underlying causes of asthma, understand the complex genetic and environmental influences, and develop appropriate treatment strategies.

7. Environmental impact:
Environmental exposures such as air pollutants and tobacco smoke play a major role in causing and aggravating asthma. In particular, exposure to tobacco smoke is a key risk factor for developing childhood asthma. In this context, additional research is needed to understand the complexity and effects of environmental factors, conclude the authors.

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