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The paradoxes of asthma management: time for a new approach?

Paul M. O'Byrne, Christine Jenkins, Eric D. Bateman
European Respiratory Journal 2017 50: 1701103; DOI: 10.1183/13993003.01103-2017
Paul M. O'Byrne
1Firestone Institute for Respiratory Health, St. Joseph's Healthcare and the Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
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  • For correspondence: obyrnep@mcmaster.ca
Christine Jenkins
2The George Institute for Global Health, Sydney, Australia
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Eric D. Bateman
3Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
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Abstract

Poor adherence to maintenance pharmacotherapy is a reality in asthma. Studies confirm that when symptoms worsen, most patients increase short-acting β2-agonist (SABA) use, instead of using controller medication. This behaviour might be attributable to several paradoxes in the current treatment approach. These paradoxes include the recommended use of a SABA bronchodilator alone at Global Initiative for Asthma (GINA) step 1, despite the fact that asthma is a chronic inflammatory disease. At step 1, the patient has autonomy and their perception of need and disease control is accepted, but at higher asthma treatment steps a fixed-dose approach is recommended, irrespective of symptom severity. The unintended consequence is the establishment of a pattern of early over-reliance on SABA. New approaches that avoid these paradoxes are needed, such as patient-adjusted therapy, in which patients adopt a symptom-driven approach using a combination reliever/controller. We propose that SABA reliever monotherapy should be replaced by a combination of inhaled corticosteroid (ICS) and formoterol, or similar rapid-onset bronchodilator, as reliever therapy for patients at GINA steps 1 or 2. This will ensure early and more regular administration of a controller medication. However, a significant body of clinical data will be needed before this approach can be approved by regulatory authorities.

Abstract

Paradoxes in asthma management, counterproductive in achieving optimal control, highlight a need for new approaches http://ow.ly/7ikh30e2tOV

Footnotes

  • Conflict of interest: Disclosures can be found alongside this article at erj.ersjournals.com

  • Received June 1, 2017.
  • Accepted June 26, 2017.
  • Copyright ©ERS 2017
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The paradoxes of asthma management: time for a new approach?
Paul M. O'Byrne, Christine Jenkins, Eric D. Bateman
European Respiratory Journal Sep 2017, 50 (3) 1701103; DOI: 10.1183/13993003.01103-2017

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The paradoxes of asthma management: time for a new approach?
Paul M. O'Byrne, Christine Jenkins, Eric D. Bateman
European Respiratory Journal Sep 2017, 50 (3) 1701103; DOI: 10.1183/13993003.01103-2017
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  • Article
    • Abstract
    • Abstract
    • Introduction
    • The asthma treatment paradoxes
    • Practical solutions to these paradoxes and the continuum of care approach
    • The continuum of care approach
    • Theoretical application of the continuum of care approach
    • Conclusions
    • Disclosures
    • Acknowledgements
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  • Asthma and allergy
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