Asthma management in Canada
Asthma is a common condition in Canadian adults, making up a significant portion of most family practices (13.3% in Ontario in 2010)(1). Symptom management, including increasing and tapering inhaled corticosteroid (ICS) therapy, can be difficult.. The College of Family Physicians of Canada (CFPC) Section of Communities of Practice in Family Medicine (CPFM) Respiratory Medicine Program Committee undertook a survey of Canadian family physicians last year to evaluate their comfort with asthma management.
The survey was distributed to two groups of family doctors via email from the CFPC. The first was to members who had expressed interest in the CPFM Respiratory Medicine group via their annual membership renewal. The second was a general distribution to all physician members of the CFPC. For more information about the Section of CPFM and its program committees, please see http://www.cfpc.ca/CPFM/.
A total of 365 surveys were returned, 159 from the respiratory group and 206 from general membership. The results were similar in both cohorts and were therefore combined.
Demographic data was collected; 52.3% of respondents have been in practice more than 15 years. Replies were received from all provinces and territories, with the most from Ontario (36.8%), followed by Alberta (17%) and Quebec (10%). 35.2% of responders identified themselves as practicing in a mid sized city, defined as a population ranging from 100,000 to 1 million. The majority (68.5%) were part of a group practice.
The majority (68.2%) felt comfortable with the management of asthma in their office. While most physicians (76%) were aware of the CTS (Canadian Thoracic Society) asthma guidelines, far fewer (24%) were aware of the GINA (Global initiative for Asthma) guidelines. For most physicians, the average wait time for specialist referral was 3-6 months.
The Canadian and GINA guidelines both address ICS use in Asthma. Both suggest ICS monotherapy at low doses to control asthma, followed by step up to ICS/ LABA (preferably in one device), if symptoms persist (after first checking for common problems such as inhaler technique, adherence, persistent allergen exposure and comorbidities). The CTS guidelines (2012) do not give clear instructions on adjusting ICS dosing, but discuss “adjusting therapy to achieve control and prevent future risk”(2). The GINA guidelines (updated 2018) state; “Consider step down once good asthma control has been achieved and maintained for about 3 months, to find the patient’s lowest treatment that controls both symptoms and exacerbations. Do not completely withdraw ICS unless this is needed temporarily to confirm the diagnosis of asthma”(3).
In our cohort, step-up and step-down therapy varied and was not necessarily done per the guideline. Despite this, most family doctors felt comfortable with their management. There seemed to be overlap in the approach to COPD and Asthma, with many family physicians using LAMA’s (like tiotropium) in their management. If you have questions or suggestions about asthma care, I would love to hear from you.
Dr Levitz is Chair, Communities of Practice in Family Medicine (CPFM) Respiratory Group.
References
1. Gershon AS, Guan J, Wang C, To T. Trends in asthma prevalence and incidence in Ontario, Canada, 1996–2005: a population study. Am J Epidemiol 2010;172(6):728-36. Epub 2010 Aug 17.
2. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults: Executive summary. M Diane Lougheed, MD MSc,1 Catherine Lemiere, MD,2 Francine M Ducharme, MD MSc,2 Chris Licskai, MD,3Sharon D Dell, MD,4 Brian H Rowe, MD MSc,5 Mark FitzGerald, MD,6 Richard Leigh, MD PhD,7 Wade Watson, MD,8Louis-Philippe Boulet, MD,9 and Canadian Thoracic Society Asthma Clinical Assembly
3. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2018. Available from: www.ginasthma.org