BNF Case Study: Managing uncontrolled asthma
June 2016

Alana Clarke is a 31 year old travel agent from Liverpool. She was diagnosed with Asthma as a child. It has been controlled and managed over the years and she has only experienced mild, intermittent symptoms. She is currently prescribed:

She is concerned that her symptoms are worsening lately and has presented today to seek your advice. Recently she has found that she is using her salbutamol inhaler almost every day and she has experienced some coughing at night, which is affecting her sleep.

What alterations will you make to Alana's current medication?

The treatment summary for Asthma outlines the aims of the management of chronic asthma. The aim is to achieve early control of the condition and to maintain this control by stepping up treatment as necessary and stepping down treatment when control is good.

Alana is currently prescribed treatment at Step 1 in the stepwise approach to management - an inhaled short-acting beta2 agonist as required. For adults and children over 5 it is recommended to move to Step 2 if the patient presents with any one of the following features:

As Alana is using her salbutamol inhaler three times a week or more and is experiencing night-time symptoms, treatment should proceed to Step 2 - Regular preventer therapy.

Are there any other considerations to be taken into account that could be affecting Alana's symptoms?

The 'Management of chronic asthma' section recommends the following steps before a new drug is initiated:

The treatment summary Respiratory system, drug delivery, outlines how patients should be instructed carefully on the use of their inhaler(s). It is important to check that the inhaler continues to be used correctly because inadequate inhalation technique may be mistaken for a lack of response to the drug.

Some non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are available for purchase by members of the public without prescription. The treatment summary Non-steroidal anti-inflammatory drugs describes how any degree of worsening of asthma may be related to the ingestion of NSAIDs, either prescribed or purchased over the counter, and this potential cause should be excluded.

You counsel Alana on her inhaler technique, and discuss potential trigger factors for the acute attacks.

What should be prescribed for Alana as regular preventer therapy (Step 2)?

Consider adding a regular inhaled standard-dose corticosteroid [alternatives to a regular inhaled corticosteroid are leukotriene receptor antagonists, theophylline, inhaled sodium cromoglicate, or inhaled nedocromil sodium - but these are less effective].

Start the inhaled corticosteroid at a dose appropriate to the severity of disease and adjust to the lowest effective dose at which control of asthma is maintained. Inhaled corticosteroids (except ciclesonide) should be initially used twice daily, however, the same total daily dose can be considered once a day if good control is established.

An inhaled standard-dose corticosteroid in Adults and children over 12 years corresponds to 200-800 micrograms/day beclometasone dipropionate or equivalent. Beclometasone dipropionate and budesonide are approximately equivalent in clinical practice although there may be variations with different drug delivery devices. Fluticasone and mometasone furoate provide equal clinical activity to beclometasone dipropionate and budesonide at half the dosage.

You and Alana agree that beclometasone dipropionate metered dose inhaler, 200-400 micrograms twice daily is an appropriate initial prescription. She will continue to use her salbutamol inhaler as required and contact you if her symptoms persist.

The recommendation to step up treatment to regular preventer therapy is annotated with an [A] grade in the BNF - what does this mean?

The guidance section, How BNF Publications are constructed, outlines how the BNF assesses the validity of evidence used to make recommendations. A five level grading system, from A to E, based on the former SIGN grading system has been adopted. This grade is displayed next to the recommendation within the text.

The grade of recommendation, A - High strength, indicates that the recommendation is based on a NICE-accredited guideline, or a source that has been deemed acceptable for an A grade using standardised methodology tools. For further information, see How BNF publications are constructed.

Alana tells you that she and her partner are planning to start a family in the coming year. She asks if it will be safe for her to continue to use these medicines if she becomes pregnant.

The section titled 'Pregnancy and breast-feeding' in Asthma outlines that it is particularly important for asthma to be well controlled during pregnancy; when this is achieved asthma has no important effects on pregnancy, labour, or on the fetus. Women planning to become pregnant should be counselled about the importance of taking their asthma medication regularly to maintain good control.

The drug monograph for salbutamol states the following and applies to all selective beta2 adrenoceptor agonists: Women planning to become pregnant should be counselled about the importance of taking their asthma medication regularly to maintain good control.

The drug monograph for beclometasone dipropionate states the following pregnancy advice, which applies to all inhaled corticosteroids:

Inhaled drugs for asthma can be taken as normal during pregnancy.

Are all preparations of beclometasone dipropionate for inhalation equivalent?

The drug monograph for beclometasone dipropionate outlines important safety information based on MHRA advice. The beclometasone dipropionate CFC-free, pressurised metered-dose inhalers Qvar® and Clenil Modulite® are not interchangeable and should be prescribed by brand name. Qvar® has extra-fine particles and is more potent than traditional beclometasone dipropionate CFC-containing inhalers. Qvar® is approximately twice as potent as Clenil Modulite®.

This case study is taken from the June 2016 issue of the BNF eNewsletter.