New Guidance Issued By BTS/SIGN Supports Use Of Single Inhaler For Maintenance And Relief In Asthmatic Patients, UK

Main Category: Respiratory / Asthma
Article Date: 09 May 2008 - 1:00 PDT

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New guidelines issued by the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) include for the first time, the practice of prescribing a single combination inhaler for both maintenance and reliever therapy in adults with poorly controlled asthma (Step 3).[i]

The UK's leading respiratory organisations have today published their updated national guidelines for the management of mild to moderate asthma. The guidelines recognise the evidence supporting the efficacy of Symbicort (budesonide/formoterol) Maintenance And Reliever Therapy (Symbicort SMART) at step 3 of asthma management1. Budesonide/formoterol is the only combination inhaler that has been recommended for this purpose within the revised guidelines as this management technique has not been investigated with other combination inhalers1.

Patients at step 3 of the asthma management programme are defined as poorly controlled on an inhaled corticosteroid (ICS) and reliever medication. The Symbicort Summary of Product Characteristics recommends the use of budesonide/formoterol for adults aged 18 years and older who are suitable for combination therapy, especially those with inadequate asthma control and in frequent need of reliever medication, as well as in patients who have had asthma exacerbations requiring medical interventions.[ii]

Symbicort SMART was launched in the UK in June 2007 and is currently the only combination inhaler licensed to be used in this way, treating the underlying inflammation with every inhalation by providing an extra dose of ICS at the point of symptom relief 2,[iii],[iv]. As with other combination asthma therapies, Symbicort SMART is not licensed for regular prophylactic use before exercise.

Commenting on the launch of the new guidelines, GPIAG Professor of Primary Care Respiratory Medicine, Dr David Price from the University of Aberdeen, said:

"It is important to update national guidelines regularly to recognise advances in the management of this common respiratory disease. Given that an estimated 75% of hospital admissions for asthma are avoidable, and as many as 90% of the deaths from asthma are preventable, there is still some way to go in the management of this condition."

"We should welcome these guidelines as a positive step forward in the management of inadequately controlled asthma patients. The revised guidelines reflect the evidence on therapeutic options that have been shown to reduce exacerbations which may result in hospitalisations and A&E visits" he continued.

It is estimated that as many as 5.2 million people in the UK have this condition, which makes asthma one of the most common chronic diseases in the UK, with prevalence increasing every year[v].

Dr Tim Harrison Consultant Physician and Associate Professor at the University of Nottingham and Nottingham University Hospitals NHS Trust commented,

"This single inhaler approach relieves acute bronchoconstriction and provides additional anti-inflammatory medication when it is needed thereby reducing acute exacerbations and overall corticosteroid load. This is in line with the overall treatment goals in asthma management to control symptoms and prevent exacerbations with minimal side effects."

He concluded "Budesonide/formoterol inhaler used as both maintenance and reliever therapy results in similar inhaled steroid use, but reduced need for oral steroids compared with using a combination inhaler purely as maintenance therapy, for many patients the usual dose is one inhalation twice daily and on average one additional daily inhalation for symptom relief."

These new BTS/SIGN guidelines coincide with the National Institute for Health and Clinical Excellence (NICE) issuing their Final Appraisal Document (FAD) "for the use of Inhaled Corticosteroids (ICS) in chronic asthma for adults and children aged 12 years and over[vi]". The NICE Committees' final guidance provides positive support for the use of a combination inhaler device for people with 'uncontrolled' asthma "where treatment with an ICS and LABA is considered appropriate"6.

Notes

1. Asthma accounts for over 1,300 deaths per year in the UK, equating to four people per day or one person every seven hours.

2. Many asthma patients require maintenance treatment with an inhaled corticosteroid, which suppresses the underlying airway inflammation, as well as a bronchodilator, which relaxes the smooth muscle of the airways

3. With Symbicort SMART, patients receive a maintenance dose of Symbicort in line with normal practice to establish asthma control and take additional inhalations 'as needed' of Symbicort if symptoms occur, to provide both rapid symptom relief and increased asthma control

4. Patients suitable for the Symbicort SMART treatment approach would no longer require a separate bronchodilator for the treatment of asthma symptoms

5. As with other combination asthma therapies, Symbicort SMART is not licensed for prophylactic use e.g. before exercise.1

6. The new BTS guidelines include Symbicort SMART for the first time as follows: "In adult patients at step 3 who are poorly controlled, the use of budesonide/formoterol in a single inhaler as rescue medication instead of a short-acting β2 agonist, in addition to its regular use as a controller treatment, has been shown to be an effective treatment option. This management technique has not been investigated with other combination inhalers. Before instituting this management careful patient education is required."

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References

[i] BTS/SIGN Guidelines. Published May 2008

[ii] Summary of Product Characteristics (SmPC) 2007

[iii] Rabe KF et al. Effect of budesonide in combination with formoterol for reliever medication on asthma exacerbations: a randomised controlled, double-blind study. The Lancet 2006;368:744-753

[iv] Bousquet J et al. Budesonide/formoterol for maintenance and relief in uncontrolled asthma vs. high-dose salmeterol/fluticasone. Resp. Med 2007;101(12):2437-46

[v] Asthma UK, . last accessed 31 March 31, 2008

[vi] Corticosteroids for the treatment of chronic asthma in adults and children aged 12 years and over. National Institute for Health and Clinical Excellence. March 2008. Final Appraisal Determination

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