The main criteria for considering reducing maintenance therapy is when a person's asthma has been controlled with their current maintenance therapy for at least 3 months.2

NG80 says that the patient should be involved in the decision to step down the therapy, and should be made aware of potential risks and benefits. In addition, the patient needs to agree how the response is monitored and reviewed.

When reducing maintenance therapy, NG80 advises:

·       stop or reduce the dose of medicines in an order that takes into account the clinical effectiveness when introduced, side effects and the person’s preference;

·       only consider stopping ICS treatment completely for people who are using low dose ICS alone as maintenance therapy and are symptom free.

Medicines optimisation

NICE has also set out medicines safety priorities for asthma to support medicines optimisation in its key therapeutic topic KTT5. In addition to advice included above, it says:14

·       Review all people with asthma who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months.

·       An ICS is the first-choice regular preventer therapy for adults and children with asthma. Adjust the dose over time, aiming for the lowest dose required for effective asthma control.

·       If a LABA is necessary in asthma, it should be prescribed with an ICS; LABAs should not be used without ICS.

·       Offer a self-management programme, comprising a written personalised action plan and education to people with asthma.

Impact of counselling

Every eight minutes, someone is admitted to hospital with an asthma attack. Around 27 people die from asthma every week, but it is estimated that two thirds of these deaths could be prevented with basic asthma care.1,4

Counselling patients is therefore very much needed in asthma management. A 2017 study looking at asthma medicines and the New Medicines Service aspect of the pharmacy contract found the intervention increased QALYs (quality-adjusted life-years) at a mean reduced cost of -£144 per patient. Increased adherence compared to normal practice translated into increased health gain at reduced overall cost, the researchers concluded.15

NG80 also asks healthcare professionals to ensure that a person with asthma can use their inhaler device. This should be done at any asthma review, whether routine or unscheduled, or whenever a new type of device is supplied.2

The importance of this was demonstrated in a study published in February 2018 assessing the physical ability of 34 people with rheumatoid arthritis to use four commonly prescribed inhaler devices. As well as dexterity, maximum inhalation flow rate was measured with an In-Check Dial device for both the RA and control groups.16

The HandiHaler, which requires seven steps to operate it properly, could only be operated successfully by 15 per cent of the people with RA, compared to the 85 per cent who could operate the Turbohaler with three steps.

Further advice about counselling patients with asthma, whether in general terms, or in the context of a Medicines Use Review, is available from the British Lung Foundation.17