Breathing new life into disease management

Abstract

Redefining the way we think about the diagnosis and management of asthma is the topic of the article by Andrew Bush and Ian Pavord on page 28, based on the Commission they authored for The Lancet in September 2017. Asthma is an extremely common problem, and I suspect that most GPs feel relatively comfortable managing it. But Bush and Pavord argue that we may be overly complacent, and that diagnosis lacks objectivity and management is inadequate. A number of the issues they raise can be extended to prescribing more generally, beyond simply asthma. Firstly, they raise the issue of more accurate diagnosis. Committing patients to long-term treatment without a firm diagnosis may lead to incorrect medication being used, unnecessary harms, and excess treatment burden. In addition, the availability of various straightforward biomarkers – in the case of asthma, exhaled nitric oxide or blood eosinophil count – can be used to help deliver more tailored treatment. The second issue that strikes me is the importance of ensuring that appropriate clinical monitoring and review is conducted to assess therapeutic response. Not doing so may result in unnecessary long-term medication, contributing to inappropriate polypharmacy. And if there is no response to treatment, perhaps there is a need to revisit the original diagnosis. Finally, prescribers must ensure that treatment is being accessed effectively. In the case of asthma, inappropriate inhaler technique is clearly an important issue, but adherence is a major barrier to drug effectiveness in all therapeutic areas. Yet despite these being such well-recognised problems, we continue to see inappropriate or ineffectual escalation of treatment rather than simply ensuring that the drug finds its way into the patient. Revisiting prescribing skills How can we improve things? Guidelines certainly have a key role in shaping practice, although I do wonder how familiar many GPs remain with them given the increasing deferral of much long-term disease management to nurses or pharmacists. Rather than simply driving forward the protocolised approach to medicine that is increasingly popular, I think there is a need to revisit more generic prescribing skills. The prescribing process is a complex one requiring a number of core competencies, starting with making a diagnosis, and ending with monitoring and reviewing the effects of the drug. The process is one that all prescribers must be familiar with – that we should ensure students are taught, but that established clinicians do not forget. Writing a prescription isn’t just about handing out a small piece of green paper at the end of the consultation, and robust diagnosis and appropriate monitoring of therapeutic response are fundamental to safe and effective use of medicines.