Breaking new ground: challenging existing asthma guidelines

Abstract

BackgroundWhile we have international guidelines and various national guidelines for asthma diagnosis and management, asthma remains poorly controlled in many children and adults. In this paper we review the limitations of current asthma guidelines and describe important issues and remaining questions regarding asthma guidelines for use, particularly in primary care.DiscussionClinical practice guidelines based on evidence from randomized controlled trials are considered the most rigorous and accurate. Current evidence-based guidelines are written predominantly from the perspective of the patient with a clear-cut asthma diagnosis, however, and tend not to consider the heterogeneity of asthma or to accommodate individual patient variations in response to treatment or their needs, differences in practice settings, or local differences in availability and cost of therapies. The results of randomized controlled trials, which are designed to establish efficacy of treatment under ideal conditions, may not apply to 'real-world' clinical practice, where patients are unselected, monitoring is less frequent, and effectiveness – the benefit of treatment in routine clinical practice – is the most relevant outcome. Moreover, most guidelines see asthma in isolation rather than considering other factors that may impact on asthma and response to asthma therapy, particularly age, allergic rhinitis, cigarette smoking, adherence, and genetic factors. When these links are recognized, guidelines rarely provide practical recommendations for treatment in these scenarios. Finally, there is some evidence that general practitioners are not convinced of the applicability of asthma guidelines to their practice settings, especially when those writing the guidelines principally work in specialist practice.ConclusionDeveloping country-specific guidelines or, ideally, local guidelines could provide more practical solutions for asthma care and could account for regional factors that influence patient choice and adherence to therapy. Pragmatic clinical trials and well-designed observational trials are needed in addition to randomized controlled trials to assess real-world effectiveness of therapies, and such evidence needs also to be considered by guideline writers. Finally, practical tools to facilitate the diagnosis and assessment of asthma and factors responsible for poor control, such as associated allergic rhinitis, limited adherence, and smoking behavior, are needed to supplement treatment information provided in clinical practice guidelines for asthma.

Not all asthma inhalers are the same: factors to consider when prescribing an inhaler

“…Furthermore, guidelines are not equipped to address the problem of inhaler misuse. 10 Using guidelines as the foundation, it is therefore the responsibility of healthcare professionals to build upon this framework in order to optimise inhaler use for each individual asthma patient.…”

Asthma incidence and accuracy of diagnosis in the Portuguese sentinel practice network

“…Due to the limitations of guidelines, 26,27 the difficulties encountered by physicians in adhering to them, 28 and difficulties in clinical practice in managing asthma in line with recommendations, 29 the International Primary Care Airways Group (IPAG) produced its own guidelines for primary care physicians in 2005. 30 Together with the IPCRG guidelines, 14 these provide a more practical approach than the GINA Guidelines.…”

Enabling and hindering factors influencing adherence to asthma treatment among adolescents: A systematic literature review

“…The Global Initiative for Asthma (GINA) is a "program to reduce asthma prevalence, morbidity, and mortality in collaboration with the World Health Organization and the National Heart, Lung, and Blood institute of the National Institutes for Health in the United States" [47]. It has developed evidence-based asthma guidelines that list common risk factors, emphasize the need to follow treatment on a regular basis, provide criteria for determining asthma severity and recommends treatment and asthma management according to asthma severity [47]. Adherence to national asthma guidelines leads to health improvements and better quality of life of asthma patients.…”