Answers

Short answers

1. Before suggesting stepping up treatment, go back to basics. Clarify that asthma is the cause of his symptoms (he may just be unfit), ask about smoking status, explore compliance, check his inhaler technique, ask about rhinitis, and consider possible triggers.

2. Once you have established that he has exercise induced symptoms related to seasonal loss of his usually good asthma control and have dealt with any problems of compliance or inhaler technique, you may follow the guideline from the British Thoracic Society-Scottish Intercollegiate Guideline Network, which recommends adding a long acting β2 agonist as first line strategy.¹ Other options include increasing the dose of inhaled steroids, adding a leucotriene receptor antagonist, or combining the long acting β2 agonist and inhaled corticosteroid in one inhaler.

3. The patient needs an action plan to reflect the new treatment regimen. He needs to know how to recognise deteriorating control and the actions he should take.

Long answers
1. Approach to the problem: back to basics
Although asthma may be the cause of his exercise induced symptoms, it is good practice to consider other possibilities and exclude other respiratory conditions, cardiovascular problems, anaemia, and so on as causes of his breathlessness. He may, of course, just be unfit. Distinguishing symptoms of exercise induced asthma are cough and wheeze or tightness in the chest, which may last for an hour after exercise,¹ and will be reflected in a fall in peak flow. Exercise induced symptoms are often a marker of poorly controlled asthma, and careful questioning revealed that the patient was also having symptoms at other times and that they had disturbed his sleep on a couple of occasions recently.

The patient was not a smoker, but if he had been this would have raised the possibility of coexistent chronic obstructive pulmonary disease, which often becomes symptomatic by the age of 40. Another reason to ask about smoking is the evidence from randomised controlled trials that current and previous smoking reduces the effect of inhaled steroids,^{2 3} so that higher doses may be needed in smokers.^{1 4}

Compliance with preventive treatment is poor—less than half the patients in this patient’s age group take their inhaled steroids regularly.⁵ The computerised repeat prescription record may provide a good indication of adherence to treatment. An open discussion, focusing on the patient’s goal of improving his "fitness" and dealing with any concerns he may have about side effects, with the aim of reaching an agreement about use of inhaled steroids, may be the best approach.¹

Up to 75% of patients make errors when using metered dose inhalers.⁶ Although teaching can improve performance,⁶ if the patient cannot use a metered dose inhaler an alternative device will need to be considered.¹

Discussion revealed that the patient currently has hay fever, which he is treating with "over the counter" antihistamines. Many patients have both asthma and rhinitis,^{7 8} and these patients incur greater prescription drug costs, visit their general practitioner more often, and are admitted to hospital for asthma more often than those with asthma alone.⁹ Evidence from cohort studies indicates that treatment of the allergic rhinitis, particularly with intranasal steroids, is associated with significant reductions in the risk of emergency room treatment and hospital admission for asthma,^{10 11} although evidence from randomised controlled trials is less clear.¹² Current guidelines on asthma and rhinitis therefore recommend treating both the upper and lower airways to achieve the best outcomes.^{1 13 14 15}

2. Treatment choices
Once you have established that the patient has exercise induced symptoms related to seasonal loss of his usually good asthma control and have dealt with any problems of compliance or inhaler technique, you may follow the guideline from the British Thoracic Society-Scottish Intercollegiate Guideline Network, which recommends adding a long acting β2 agonist as first line strategy.¹ Other options include increasing the dose of inhaled steroids, adding a leucotriene receptor antagonist, or combining the long acting β2 agonist and inhaled corticosteroid in one inhaler.

The addition of a long acting β2 agonist to a modest dose of inhaled steroids can reduce symptoms and the need for rescue drugs, improve quality of life, and reduce exacerbations.^{16 17} This approach is now recommended as the first line "add on" treatment for patients whose asthma is not controlled by inhaled steroids.^{1 4} There are, however, other options that you and the patient may wish to consider.

Inhaled steroids reduce exercise induced asthma,^{1 4} and it is important to ensure that the patient is receiving an adequate dose of beclometasone. The presence of symptoms at other times, especially at night, suggests that the dose of beclometasone might need to be increased. Other factors that may need to be discussed include the frequency of exacerbations, because increasing the dose of inhaled steroids may reduce severe exacerbations more effectively than add on treatment.^{4 18}

Leucotriene receptor antagonists can reduce the symptoms of rhinitis and might be effective against both manifestations of the patient’s allergy.¹⁹ They are effective in exercise induced asthma and, unlike long acting β2 agonists, tolerance does not develop.¹ The patient may also have a preference for inhaled or oral treatment, which may affect his choice.

Combination inhalers offer the convenience of taking inhaled steroids and a long acting β2 agonist in one inhaler. All patients taking long acting β2 agonists for asthma should be counselled to maintain their regular dose of inhaled steroids, to protect against the "rare but real problem" of an increased risk of asthma related deaths in patients using long acting β2 agonists only.^{20 21 22} Prescribing a combination inhaler will ensure that the patient complies with his regular inhaled steroid treatment while using the long acting β2 agonist.^{1 4} However, this may make stepping down treatment—for example, at the end of the hay fever season when he may no longer need the long acting β2 agonist—more complicated. Long acting β2 agonists produce side effects (mostly tremor and palpitations) in some patients, which may prevent their use.

3. Self management
All patients with asthma should have an action plan advising them how to respond to a deterioration in their asthma.^{1 4 23} In line with evidence, the patient already has a plan, based on symptoms and his best peak flow, which advises him when to increase his inhaled steroids, when to start a course of oral steroids, and how to respond in an emergency.²⁴ Suitable asthma action plans are available from Asthma UK (www.asthma.org.uk).

His plan needs to be revised to ensure that he understands how any new treatments should be used and adjusted to maintain control. His personalised plan should also include advice on avoiding pollen and a reminder to restart his nasal steroids at the beginning of the season.¹⁵

If the patient opts for a combination inhaler, his plan will need to include advice on stepping down treatment at the end of the hay fever season and returning to his usual inhaled steroid regimen, as well as stepping up at the beginning of the next season. If he is using a combination containing salmeterol he will need an additional inhaled steroid to enable him to increase the dose in the event of an exacerbation. Combinations including formoterol may be used flexibly by increasing the dose of the combination to maintain control.²⁵

Outcome

Discussion with the patient revealed that several factors had reduced the potential benefit of the prescribed beclometasone. He disliked taking regular treatment and had only recommenced inhaled steroids when his symptoms had become troublesome a couple of weeks ago. In addition his inhaler technique was not ideal.

With the help of the asthma nurse he chose a breath actuated metered dose inhaler, which he was better able to use. He increased the dose of beclometasone to 200 µg twice a day and agreed to start regular use of a steroid nasal spray to control his rhinitis.

A review was arranged for two weeks later. At that time his symptoms had settled almost completely so there was no need to consider starting additional drugs. He maintained control with beclometasone 200 µg twice a day until the end of the pollen season when he stepped down to his usual maintenance dose. His action plan was revised to include advice about stepping up treatment at the onset of the hay fever season.

Cite this as: BMJ 2008;337:a1963