New evidence-based tool to guide the creation of asthma action plans for adults

Case description

Janette, a 35-year-old woman with objectively diagnosed asthma, presents to her family physician for a regularly scheduled follow-up visit. She is currently using a high-dose inhaled corticosteroid (ICS) and long-acting β-agonist (LABA) combination (fluticasone-salmeterol disk-inhaler, 250/50 μg, 1 puff twice daily) as controller therapy, with salbutamol as needed for rescue therapy. Despite good adherence to this therapy and adequately controlled day-to-day asthma symptoms, she has between 1 and 2 asthma exacerbations each year requiring emergency department visits. In addition to reviewing Janette’s adherence and inhaler technique, and identifying and treating modifiable risk factors for exacerbations (such as avoidance of work- and home-related asthma triggers), the primary care physician wonders whether Janette would benefit from an individualized written action plan to hopefully allow earlier therapy adjustment and prevent such serious exacerbations. If so, how could she work with Janette to create one in an efficient and evidence-based manner?

Sources of information

Evidence base for asthma action plans (AAPs).

Asthma action plans are personalized written plans created by health care professionals in collaboration with patients with asthma; they are designed to provide guidance for self-management of acutely worsening asthma (Figure 1). These plans use a “traffic light” configuration: a “green zone” describes acceptable control and lists baseline medications, a “yellow zone” details loss of control and instructions for transiently intensifying therapy, and a “red zone” indicates severe symptoms that require urgent medical attention.¹ The effect of AAPs has been studied extensively across a range of contexts. A 2003 Cochrane review of randomized controlled trials (RCTs) showed that the use of AAPs, when coupled with adequate education and regular clinical review, significantly reduced asthma hospitalizations (relative risk [RR] of 0.58, 95% CI 0.43 to 0.77), emergency department visits (RR = 0.78, 95% CI 0.67 to 0.91), and nocturnal symptoms (RR = 0.57, 95% CI 0.45 to 0.72), and improved quality of life (standard mean difference of 0.29, 95% CI 0.11 to 0.47) in adults (level I evidence).² Patients were recruited from various care settings, including outpatient general practice clinics and inpatient settings. A 2015 Cochrane review of RCTs and non-randomized controlled trials showed that in adult asthma patients, a chronic disease management program predominantly including structured follow-up, individualized asthma education, and AAP provision improved asthma-specific quality of life, asthma severity scores, and lung function tests (level I evidence).³ Most included studies recruited patients from primary care clinics or pharmacies. A more recent meta-review of 27 systematic reviews and 13 additional RCTs found that supported self-management of asthma including an AAP reduced hospitalizations and unscheduled consultations, and improved quality of life (level I evidence).⁴ This evidence was consistent across cultural, demographic, and health care settings. In keeping with this breadth of evidence, international asthma guidelines strongly recommend that all patients with asthma receive a written AAP.⁵ The patient described above would particularly benefit from an AAP in combination with education and regular clinical review, given her history of exacerbations.

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Figure 1.

Janette’s asthma action plan

Main message

Despite the body of evidence in favour of AAPs and consistently strong recommendations for their use across international asthma guidelines, studies found that only 4% of family physicians reported consistently providing a written AAP and only 2% of patients actually received one.^14,15 Evidence suggests that inadequate training and knowledge regarding appropriate AAP content—particularly what therapy to recommend in the AAP’s acute-loss-of-control (yellow) zone—represents an important barrier to AAP provision in family practice.^16–18 In fact, there is an adequate evidence base to guide best therapy in the AAP yellow zone. In RCTs, increasing the ICS dose by 4- to 5-fold for 7 to 14 days during acute loss of asthma control as part of an AAP yellow zone has been shown to reduce the need for oral corticosteroids, whereas only doubling the dose has been ineffective (level I evidence).¹⁹ However, it is not always clear whether and how a 4- to 5-fold dose increase can be put into real-world practice. For example, dose augmentations in patients taking moderate or high ICS doses, or those taking combination ICS-LABAs, might often result in ICS or LABA doses that exceed regulatory limits. Furthermore, a 4- to 5-fold ICS dose increase can be achieved in various ways, including adjusting the number, the frequency, or both of inhalations of the baseline inhaler; temporarily adding a new ICS inhaler; or temporarily changing to a new inhaler. Unfortunately, guidance as to the optimal approach is lacking in existing asthma guidelines.⁵ These practical implementation challenges pose an important barrier to effective AAP provision in primary care.

To address these gaps, a set of evidence-based principles for determining required doses and also for practically “formulating” yellow-zone medications have recently been proposed.⁵ (See tables 2 and 3 in Kouri et al⁵ available at erj.ersjournals.com/content/49/5/1602238#T2). These principles were then applied to develop a practice tool in the form of a printable bedside chart listing each appropriate yellow-zone recommendation for various corresponding baseline (green zone) medication regimens (erj.ersjournals.com/content/erj/49/5/1602238/DC1/embed/inline-supplementary-material-1.pdf?download=true).⁵ This tool also provides guidance on the appropriate use of oral corticosteroids in the context of an AAP in patients who fail to improve clinically with an increase in their controller medication and in those with a history of sudden and severe exacerbations, and it discusses the implications for AAPs of the use of budesonide-formoterol as maintenance and reliever therapy.⁵

Case resolution

Janette and her family physician discuss the idea of asthma self-management and decide that it would be a beneficial approach to avoiding asthma-related emergency department visits and to improving Janette’s quality of life. They discuss the different elements of an AAP. For her yellow zone, after consulting the practical tools outlined above,⁵ they choose to maintain the controller fluticasone-salmeterol disk-inhaler and to add a fluticasone disk-inhaler (250 μg), 3 puffs twice daily for 7 days, to achieve a total daily fluticasone dose of 2000 μg during periods of loss of asthma control (Figure 1). This represents a 4-fold increase in Janette’s ICS dose without increasing her LABA dose, which was already at its allowable limit. The physician then provides brief asthma education, reviewing Janette’s asthma control, medication adherence, and inhaler technique; discusses modifiable risk factors for poor control, such as smoke and allergen exposure; and provides Janette with a link to further self-directed online asthma educational resources (Box 1).⁵ Follow-up in 6 months was then arranged to review Janette’s asthma control.

Conclusion

This novel point-of-care tool aims to both address knowledge barriers and to increase the efficiency of developing AAPs in family practice. Other barriers, such as the time required to provide AAPs and asthma education, and the lack of availability of AAPs at the point of care, can be addressed in the future by integrating this knowledge into a computerized clinical decision support system, which can automate many of the required steps in AAP generation and delivery.²⁰ Patient-level barriers, such as adherence and inhaler technique, are equally important aspects of ensuring optimal asthma therapy²¹ and should be integrated into future asthma self-management tools.