All About Asthma - Can consistent asthma treatment make a difference in patient outcomes?

What is the goal of asthma management?

The goal of asthma management is to suppress the inflammation as well as treat the bronchoconstriction and related symptoms. Once treatment has been initiated improvement in symptoms may begin within days. However, the full benefit may only be evident after 3 to 4 months of therapy and can take longer in severe and chronically undertreated disease. Once asthma control has been achieved therapy should be stepped down to the minimum dose to maintain control.


What is the role of maintenance medication in asthma management?

Maintenance medication plays an important role in maintaining asthma control, i.e. limiting symptoms, through controlling the airway inflammation and reducing airway hyperresponsiveness to triggers or risk factors. Once asthma control is achieved there is a reduced need for medication and medication should be stepped down to the minimum dose to maintain control. (GINA Report 2008) However, it is important to remember that asthma is a chronic disease with a complex pathophysiology. What we observe as asthma symptoms is merely just the tip of the iceberg as there is a lot going on unseen, below the surface, in the airways.


Airway hyperresponsivess is a measure that reflects “sensitivity” of the airways to factors (i.e. triggers) that can cause asthma symptoms and may be linked to structural changes in the airways (i.e. airway remodeling) that may be driven, at least in part, by ongoing inflammation.


1. How can consistent asthma treatment make a difference in patient outcomes?

We know that there is much more to asthma than the moment-to-moment symptoms. What we observe as asthma symptoms is merely just the tip of the iceberg as there is a lot going on unseen, below the surface, in the airways. In the past physicians focused on symptoms, but we now understand that we need to consider and treat the underlying inflammation. Recent studies have begun to reveal that if asthma is treated regularly and continuously then people’s asthma becomes more stable. Continuous
treatment for months and even years leads to a less hyperresponsive airway or an airway that is less twitchy in response to triggers. For better patient outcomes we need to not just treat the visible moment-to-moment symptoms but to treat the ongoing hidden airway inflammation.


2. Why is it important to maintain treatment even after symptoms and lung function are improved?

We know that some symptoms like nighttime awakening should disappear quite quickly (days) with adequate anti-inflammatory therapy. However, other symptoms may take longer to resolve, with personal best peak flow and FEV1 taking days to weeks to return to normal and bronchial hyperresponsiveness taking months to years to improve. What this means is when we treat a patient we need to consider lung function and airway stability more than symptoms. This will require long-term daily antiinflammatory therapy. One concerning thing I have observed is that some physicians are returning to a symptom-driven approach to asthma management with their patients. As in most chronic diseases patients are poorly adherent especially when they are symptom free. As a path of least resistance, some physician’s are permitting patients to self-care, treating only their symptoms and ignoring the unseen inflammation. This method of managing asthma may be dangerous as patients are hyperresponsive to asthma triggers, leading to more asthma symptoms and attacks and possibly hospitalization or death. We have observed in other chronic disease/ disorder situations that disease education and a consistent message can change how a patient views and manages their disease. We need to do that in managing asthma with a focus around airway inflammation.


3. Are most patients with persistent asthma able to appropriately self-adjust their medications to prevent symptoms and/or attacks?

Experience teaches us that most patients use their bronchodilator (reliever medication) to address worsening symptoms and not their anti-inflammatory medication (asthma controllers). With good education it is possible to help them self-adjust their medication, however evidence suggests that patients cut back on their anti-inflammatory medication before their asthma is well controlled. There are also the confounding patients, those who are the poor perceivers and those who are hyper-perceivers. Moment-to-moment symptom management does not work in poor perceivers as they are unable to determine a drop in lung function and so are unable to modify their asthma medication accordingly. Hyper-perceivers are in danger of overmedicating as they perceive symptoms with only a minimal drop in lung function.

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