Asthma is a common and growing clinical problem world-wide with Ireland having one of the highest rates for the disease. While it carries a high morbidity there is currently effective medications for the treatment of the condition. In recent years our knowledge of the mechanisms underlying the asthma condition has shown that airway inflammation is an important component of the disease. Thus inhaled corticosteroids are the primary treatment recommended for most asthmatics. Many countries and most recently Ireland have established and published asthma management guidelines to help improve practice in dealing with the condition.
Clinical practice guidelines offer a number of advantages which include an up-to-date summary of research for the practising clinician, they enable standards to be set and provide the basis for audit. In addition, they form the basis for education of all health care professionals and encourage a common approach to management of this condition. The ICGP asthma guidelines (Fig 1) developed and updated by the National Clinical Programme for Asthma in conjunction with Asthma Society of Ireland and the Quality in Practice (QIP) Committee of the Irish College of General Practice (ICGP) is based on the international evidence-based Global Initiative in Asthma (GINA) / World Health Organisation (WHO) document are designed to do this. The GINA/WHO publication is was published initially in 1995 and regularly updated. It has been developed with current medical knowledge about asthma and its treatment.
However, no matter how up-to-date the current asthma guidelines are, a major barrier to effective use of anti-asthma therapy is patient adherence. Studies have consistently shown that perhaps about one third of patients will take medicines as prescribed. One has to assume that this may also be the case with asthma therapy. This issue of adherence to medications, is very complex and includes a variety of medical, social and cultural factors (Table 1).
Adherence is not simply a matter of patients following the doctors’ orders but it closely entails the patient’s own involvement in the management of their condition. The patient makes various decisions regarding their condition, from visiting the doctor initially, to heeding the doctor’s recommendations and subsequently agreeing and adhering to follow up and monitoring of their asthma condition.
The significant factors in aiding adherence with asthma therapy includes simplifying treatment regimes, addressing the patient’s concerns or expectations about treatment and involving the patient, parent and close relative if necessary, in partnership in ongoing care. These asthma guidelines are designed to address this issue of adherence by emphasising the need to involve patients as partners in the care of their condition, to overcome barriers with appropriate education and thus promote adherence. In addition, the availability and expertise of the asthma practice nurse has helped tremendously, and will no doubt continue do so into the future, to meet these goals in clinical practice.
For most asthmatics there is a need for at least two types of medications, the anti-inflammatory preventor (generally inhaled corticosteroids) and inhaled reliever (e.g. β2-agonists). Medication, particularly inhalers, can be difficult to administer, and can have negative effects if not administered properly. In addition, asthmatic may also require life-style changes (e.g. allergen avoidance or smoking cessation) as part of their asthma management.
Control of asthma requires continual long-term care and monitoring by the clinician. This should include review of symptoms and measurement of lung function with at least peak flow measurement at each clinic visit. Long term monitoring of peak flow rates by patient at home can aid in the recognition by the patient of early signs of worsening asthma to enable patients to act promptly and avoid a serious attack. Regular visits as appropriate are essential even after control is established and it is helpful to review the following questions (Table 2).