Guidelines

Impacts on Guidelines

GINA 2019:

Levy ML, Fletcher M, Price DB, Hausen T, Halbert RJ, Yawn BP. International Primary Care Respiratory Group (IPCRG) Guidelines: diagnosis of respiratory diseases in primary care. Prim Care Respir J 2006;15(1):20-34. [PubMed] [Full Text]

  • Highlights the importance of using a symptom-based or syndromic approach when diagnosing asthma and establishes a questionnaire that can be used to do so.
  • Low- and middle-income countries (LMIC) are not the only regions with insufficient resources to diagnose and treat respiratory disease – affluent countries may also experience this issue.
  • A symptom-based or syndromic approach allows primary care physicians to accurately differentiate asthma (and COPD) from other respiratory diseases via a questionnaire.
  • The first step is to characterize the problem: the symptoms the patient experiences are identified, infectious diseases and non-respiratory causes are ruled out and chronicity is established.
  • The second step is to consider the patient’s age: Children are more likely to have asthma whereas adults aged 40+ are more likely to have COPD (although asthma is still possible).
  • The third step is to investigate the possible chronic airway diseases.

Thomas M, Kay S, Pike J, Williams A, Rosenzweig JR, Hillyer EV, Price D. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J 2009; 18(1):41-9. [PubMed] [Full Text]

  • Measuring asthma control in patients can provide a better reflection of the effectiveness of therapeutic interventions – it therefore acts as a better guide for treatment when compared to simply evaluating disease severity.
  • The Asthma Control TestTM (ACT) is a validated, patient-completed questionnaire that assesses asthma control in patients over the previous four weeks.
  • This study determined that the ACT could accurately predict GINA-defined asthma control. It also identified an ACT score of ≤19 as indicating poorly controlled asthma as defined by GINA.

Price DB, Hernandez D, Magyar P, Fiterman J, Beeh KM, James IG, Konstantopoulos S, et al. Randomised controlled trial of montelukast plus inhaled budesonide versus double dose inhaled budesonide in adult patients with asthma. Thorax 2003;58(3):211-6. [PubMed] [Full Text]

  • Patients at GINA Step 4 are recommended low dose inhaled corticosteroids (ICS) which can be increased to medium dose if asthma is still uncontrolled.
  • However, ICS do not affect cysteinyl leukotrienes, which could be a factor in why some patients still experience uncontrolled asthma.
  • Montelukast, a leukotriene receptor antagonist (LTRA) can be used in conjunction with ICS to reduce airway inflammation and better control asthma.

Price D, Robertson A, Bullen K, Rand C, Horne R, Staudinger H. Improved adherence with once-daily versus twice-daily dosing of mometasone furoate administered via a dry powder inhaler: a randomized open-label study. BMC Pulm Med 2010;10:1. [PubMed] [Full Text]

  • Poor medication adherence is a major factor contributing to poor treatment outcomes, however, adherence can be improved by reducing the number of times a patient needs to take their medication in one day.
  • Patients were more likely to adhere to their medication regimen of inhaled corticosteroids (ICS) via a dry powder inhaler when they only had to use their inhaler once a day, as compared to twice a day.

Price DB, Tinkelman DG, Halbert RJ, Nordyke RJ, Isonaka S, Nonikov D, Juniper EF, et al. Symptom-based questionnaire for identifying COPD in smokers. Respiration 2006;73(3):285-95. [PubMed] [Full Text]

  • Asthma and COPD often present with similar symptoms in adults, and it is therefore difficult to distinguish between the two. Furthermore, it is also difficult to distinguish between these diseases and asthma-COPD overlap (ACO).
  • While spirometry is considered to be the best way to diagnose COPD, it may not always be possible due to a variety of reasons including lack of equipment or appropriately trained personnel. Therefore, this study proposes a patient self-administered questionnaire to help identify those at risk of COPD so they can be referred for spirometry.
  • This is one method of investigation to identify patients with COPD and exclude them from having asthma – more steps will be required to conclusively diagnose them with asthma.

Tinkelman DG, Price DB, Nordyke RJ, Halbert RJ, Isonaka S, Nonikov D, Juniper EF, et al. Symptom-based questionnaire for differentiating COPD and asthma. Respiration 2006;73(3):296-305. [PubMed] [Full Text]

  • This study details a short, patient self-administered, symptom-based questionnaire that clinicians can use to differentiate between asthma and COPD.

Robertson CF, Price D, Henry R, Mellis C, Glasgow N, Fitzgerald D, Lee AJ, et al. Short-course montelukast for intermittent asthma in children: a randomized controlled trial. Am J Respir Crit Care Med 2007;175(4):323-9. [PubMed] [Full Text]

  • Discovered that a short course of oral montelukast, a leukotriene receptor antagonist (LTRA), reduces symptoms, health care utilization and time off work for the carer of an asthmatic child aged 2-5 years.
  • It should be administered for 7-20 days at the start of an upper respiratory tract infection or at the first sign of asthma symptoms.

GOLD 2019:

Jones RC, Donaldson GC, Chavannes NH, Price D, et al. Derivation and validation of a composite index of severity in chronic obstructive pulmonary disease: the DOSE Index. Am J Respir Crit Care Med 2009; 180(12): 1189-95. [PubMed] [Full Text]

  • This study describes the DOSE Index, which provides a composite score that can be used to assess the severity of COPD. It is simpler than the current standard, the BODE method, but it requires further validation across disease severities and clinical settings.

Price D, Yawn B, Brusselle G, Rossi A. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. Prim Care Respir J 2013; 22(1): 92-100. [PubMed] [Full Text]

  • Highlights the fact that using inhaled corticosteroids (ICS) to treat COPD can result in adverse effects such as pneumonia, osteoporosis, diabetes and cataracts.

Brusselle G, Price D, Gruffydd-Jones K, et al. The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK. Int J Chron Obstruct Pulmon Dis 2015; 10:2207-17. [PubMed] [Full Text]

  • Triple therapy refers to the prescribing of a long-acting beta-agonist (LABA) bronchodilator with a long-acting muscarinic antagonist (LAMA) and an inhaled corticosteroid (ICS). It is prescribed to those with particularly severe COPD, classified as GOLD group D.
  • Currently, real-world prescription pathways leading up to triple therapy are not standardized and differ from guideline recommendations.
  • This study provides a comprehensive overview of these different prescription pathways that occur in COPD patients, beginning at the time of diagnosis to the first prescription of triple therapy.

NICE Guidelines for Asthma 2017:

Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ 2003; 326(7387):477-479. [PubMed] [Full Text]

  • Found that telehealthcare interventions such as telephone consultations with an asthma nurse are a viable and effective alternative to face-to-face consultations.
  • Telephone consultations tend to be shorter than face-to-face consultations; this enables more patients to be reviewed.
  • Patient satisfaction, quality of life and symptom scores, as well as the number of acute asthma exacerbations and the use of healthcare resources, did not differ much between patients who underwent telephone consultations and those who underwent face-to-face consultations.

BTS/SIGN 2019:

Blakey JD, Price DB, Pizzichini E, Popov TA, Dimitrov BD, Postma DS, et al. Identifying Risk of Future Asthma Attacks Using UK Medical Record Data: A Respiratory Effectiveness Group Initiative. J Allergy Clin Immunol Pract 2017;5(4):1015-24.e8. [PubMed] [Full Text]

  • Identified the factors associated with an increased risk of an acute asthma attack in adults.
  • A greatly increased risk of an asthma attack was associated with previously experiencing asthma attacks.
  • A moderately increased risk of an asthma attack was associated with inappropriate or excessive short-acting beta-agonist (SABA) use.
  • A slightly increased risk of an asthma attack was associated with older age, being female, having reduced lung function (PEF or FEV1), being obese and smoking.
  • The level of risk was unclear when it came to the factors of having a history of anaphylaxis, having comorbid gastro-oesophageal reflux, blood eosinophilia and poor medication adherence.

Price D, Wilson AM, Chisholm A, Rigazio A, Burden A, Thomas M, et al. Predicting frequent asthma exacerbations using blood eosinophil count and other patient data routinely available in clinical practice. J Asthma Allergy 2016;9:1-12. [PubMed] [Full Text]

  • Identified the factors associated with an increased risk of an acute asthma attack in adults.
  • A greatly increased risk of an asthma attack was associated with previously experiencing asthma attacks.
  • A moderately increased risk of an asthma attack was associated with inappropriate or excessive short-acting beta-agonist (SABA) use.
  • A slightly increased risk of an asthma attack was associated with older age, being female, having reduced lung function (PEF or FEV1), being obese and smoking.
  • The level of risk was unclear when it came to the factors of having a history of anaphylaxis, having comorbid gastro-oesophageal reflux, blood eosinophilia and poor medication adherence.

Cleland JA, Hall S, Price D, Lee AJ. An exploratory, pragmatic, cluster randomised trial of practice nurse training in the use of asthma action plans. Prim Care Respir J 2007;16(5):311-8. [PubMed] [Full Text]

  • Shows how implementing written personalized asthma action plans (PAAPs) in a primary care setting improves health outcomes for people with asthma.
  • Found that only one health outcome – the mini asthma quality of life questionnaire (AQLQ) score – was improved.

Robertson CF, Price D, Henry R, Mellis C, Glasgow N, Fitzgerald D, et al. Short-course montelukast for intermittent asthma in children: a randomized controlled trial. Am J Manag Care 2007;175(4):323-9. [PubMed] [Full Text]

  • Discovered that a short course of oral montelukast, a leukotriene receptor antagonist (LTRA), reduces symptoms, health care utilization and time off work for the carer of an asthmatic child aged 2-5 years.
  • It should be administered for 7-20 days at the start of an upper respiratory tract infection or at the first sign of asthma symptoms.

Ryan D, Price D, Musgrave SD, Malhotra S, Lee AJ, Ayansina D, et al. Clinical and cost effectiveness of mobile phone supported self monitoring of asthma: multicentre randomised controlled trial. BMJ 2012;344:e1756. [PubMed] [Full Text]

  • Discovered that a short course of oral montelukast, a leukotriene receptor antagonist (LTRA), reduces symptoms, health care utilization and time off work for the carer of an asthmatic child aged 2-5 years.
  • It should be administered for 7-20 days at the start of an upper respiratory tract infection or at the first sign of asthma symptoms.

Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D, et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. British Medical Journal 2003;326(7387): 477-9. [PubMed] [Full Text]

  • Found that telehealthcare interventions such as telephone consultations with an asthma nurse are a viable and effective alternative to face-to-face consultations.
  • Telephone consultations tend to be shorter than face-to-face consultations; this enables more patients to be reviewed.
  • Patient satisfaction, quality of life and symptom scores, as well as the number of acute asthma exacerbations and the use of healthcare resources, did not differ much between patients who underwent telephone consultations and those who underwent face-to-face consultations.