Management of mild to moderate asthma has transformed in recent years as evidence for dual therapy has increased.

Inhaled corticosteroids, along with a short or long-acting bronchodilator, are now the cornerstone of management when treating mild to moderate disease.

By understanding the evidence base and clinical rationale that led to dual therapy becoming first line in asthma management, GPs can confidently optimise lung function and symptom control for their patients.

Dr David Freiberg, a respiratory and sleep physician, will be unravelling the major studies that led to these significant changes in guidelines and clinical practice in the next Healthed webcast on 13 June.

Dr Freiberg explains that asthma, which is characterised by chronic airway inflammation and hyperresponsiveness, requires regular anti-inflammatory therapy to normalise the airway and reduce the risk of severe exacerbations.

“Very few patients these days should be on short acting bronchodilator therapy alone. You should consider using a combination of inhaled corticosteroids and long-acting beta-agonist on an as needed basis. Or alternatively, if you can convince your patient to use a regular daily treatment, a daily inhaled corticosteroid will result in the best possible control,” Dr Freiberg says.

The importance of inhaled corticosteroid is long established; a study from over two decades ago published in the New England Journal of Medicine showed that regular use of inhaled corticosteroids was associated with a decreased risk of death from asthma.

Dr Freiberg says that the reason for this lies in the anti-inflammatory effect of inhaled corticosteroids that can completely normalise the morphology and histology of the bronchial epithelium in people with asthma.

More recently, the evidence shows that as-needed regimens are inferior to regular daily dosing when it comes to improving lung function. However, not everyone will be willing to adhere to daily dosing regimens and therefore getting an as-needed dose of inhaled corticosteroids is better than getting no corticosteroid at all— it will still reduce the risk of severe exacerbations. For this reason, the vast majority of patients should be using inhaled corticosteroids in their asthma management.

“Getting some inhaled corticosteroid in, even on an as needed basis versus using it regularly, both equally and significantly reduces the risk of severe asthma exacerbations and there was no difference between as-needed inhaled steroids and regularly inhaled corticosteroids for [reducing the risk of] severe exacerbations,” Dr Frieberg explains.

Key points to remember when prescribing dual therapy for asthma management:

• Asthma is a chronic condition characterised by airway inflammation that almost always requires inhaled corticosteroids
• Regular inhaled corticosteroid use is superior to ‘as needed’ use for asthma symptoms control in mild asthma
• Ensuring the appropriate inhaler technique and selecting an easy-to-use inhaler is important
• Once daily dosing may increase adherence when compared to twice daily regimens

The longer inhaled corticosteroids are used, the greater the benefits, “the very brittle and concerning symptom of waking with night-time symptoms will go within days of adding an inhaled corticosteroid, lung function will improve and plateau over weeks to a few months. The need for a short acting beta-agonist will significantly reduce, but will always be there,” Dr Freiberg explains.

Maximising adherence to treatment regimens and ensuring proper device technique are also important factors in optimising management. Emerging evidence suggests that once daily dosing may lead to better adherence, and some devices are less prone to user error than others. By ensuring asthma is appropriately management, GPs can prevent severe exacerbations, hospitalisation and improve symptom control and lung function in their patients.

Dr David Freiberg will be speaking at Healthed’s upcoming Webcast on 13 June. To hear more on this topic register here.