The benefit of experience: patient perception of asthma self-management.

Many national and international asthma guidelines contain strong evidence-based recommendations for the provision of written asthma action plans to patients with asthma. In an editorial in this journal in 2004, Gibson highlighted the mismatch between the available evidence for the efficacy of written action plans and for their components, and the proportion of patients who had been given a written action plan. Since then, there has been further evidence of the decline in patient ownership of action plans. Insight into reasons behind the lack of adoption of asthma action plans has come from several sources. Goeman and colleagues found that general practitioners (GPs) place a low priority on action plans, particularly those plans that encourage self-management. Jones and colleagues highlighted the negative effect — on clinicians’ use of action plans — of confusion about what the instructions should be, and concerns about whether self-management was an appropriate strategy. It has been known for some time that the attributes of guidelines themselves affect the likelihood of their uptake, with vague and nonspecific guidelines less likely to be adopted. The lack of clearly-defined protocols for action plans is a significant disincentive for their use. This immediately highlights a current problem with the specific content of asthma action plans, because of recent evidence about some action plan components which were originally considered to be ‘standard’. The action plans which were included in the original Cochrane review used a wide range of trigger points and interventions, but most included an instruction to patients to double the dosage of their inhaled corticosteroid (ICS) treatment at the start of an asthma exacerbation, and to initiate a course of oral corticosteroids for more severe episodes. However, several recent placebo-controlled clinical trials have shown that doubling of ICS dose is not effective in the management of asthma exacerbations. The removal of this option leaves a conspicuous gap in the current options for construction of an action plan. Oral corticosteroids are cheap and effective in the treatment of severe exacerbations. However, further information is needed about the extent to which patients, with their known reluctance to use corticosteroid medications, would accept an action plan which moved straight from short-acting ß2-agonist to oral corticosteroids. As such plans would result in increased use of oral corticosteroids in the community, more data are also needed about the potential for overuse of oral corticosteroids and for cumulative side-effects. Although doubling of ICS dose is now known to be ineffective, several studies have provided evidence for the efficacy of higher-dose ICS as an intermediate step in the management of exacerbations. A similar approach was also used in several open-label studies of so-called Adjustable Maintenance Dosing using Symbicort (combination inhaled corticosteroid — budesonide — and rapidonset, long-acting ß2-agonist — formoterol). For example, in the study by Ind and colleagues, patients were reduced to a low maintenance dose of Symbicort and were instructed to increase the dose to four puffs twice daily for up to 14 days for specified changes in symptoms (night waking on two consecutive nights, or reliever use ≥3 times/day); this treatment was compared with a higher fixed dose of Symbicort. Although the Copyright GPIAG Reproduction prohibited