When coughing up is essential
GPs are under constant pressure from health authorities to reduce prescribing costs, and nowhere is this more obvious than in the treatment of asthma.
This common condition consumes much doctor time, and usually needs some kind of inhaled therapy. At its simplest, it could be occasional use of an inhaler to relieve symptoms (a bronchodilator treatment such as salbutamol or terbutaline).
The next step is to prescribe a preventer drug (usually an inhaled steroid such as beclomethasone, budesonide or fluticasone). There are, in addition, protector drugs such as the long-acting bronchodilator salmeterol. This helps keep airways patent and is one of the options for patients who have not improved with simpler treatments.
I recently had the chance to review my practice's treatment, specifically of those patients prescribed one of the more expensive drugs, Seretide. This is a combination inhaler of the steroid fluticasone with the long-acting bronchodilator salmeterol. My review was prompted by a severe case of palpitations - mine, when I learned exactly how much I had spent on this one drug in the past three months.
I found that a small group of the most severe asthmatics in the practice were on this drug, which was no real surprise.
What was gratifying was the realisation that not one of them had been admitted to hospital for asthma in the past two years. Winters are often bad for these patients. Cold air alone makes the airways tighten. Then there are colds, flu and the other infections that are part and parcel of this time of year.
Inhalers are not, of course, the only thing keeping this little group of people out of hospital - I must also thank flu jabs, asthma nurses, as well as the patients themselves and their increasing expertise in managing their condition.
I could have spent a lot less of the taxpayer's cash on asthma treatment. However, as a GP with a special interest in chest disease eloquently puts it: 'If your prescribing costs are only average, then you're under-treating asthma.' Many other doctors, and the published evidence, support his view.
A recent meta-analysis of the use of increased doses of inhaled steroid as compared with adding salmeterol is convincing: adding the long-acting bronchodilator drug works better than doubling the dose of steroid.
1And, I would add, it is more acceptable to patients. No wonder the British Thoracic Society guidelines incorporate the use of this drug when asthma is not controlled by regular low-dose inhaled steroids.
2Inhaled salbutamol costs the NHS around£2 a month per patient, while inhaled beclomethasone in low doses adds only about£4.60 to this.
Combination drugs like high dose Seretide, on the other hand, can top£65 a month. But that may be the price of keeping patients off the wards and at their desks, as well as helping to reduce asthma mortality, which is currently dropping by around 6 per cent a year. Good control of asthma takes effort and money. Resources are finite but I agree with most of my colleagues that the problem is unlikely to be solved by therapeutic short-termism.
1 Shrewsbury S, Pyke S, Britton M. Meta-Analysis of Increased Dose of Steroid or Addition of Salmeterol in Symptomatic Asthma (MIASMA). BMJ 2000; 320: 1368-1373.
2 The British Thoracic Society et al. The British Guidelines on Asthma Management, 1995 review and position statement. Thorax 1997; 52 (suppl 1): 1-21.