Treatment for asthma has been completely transformed over the last 70 years.
Over 300 million people have asthma around the world and in the UK 5.4 million people are currently receiving treatment for this condition. Asthma costs the NHS over a billion pounds a year.
I look after people with severe asthma, which is defined as asthma that doesn’t respond to the usual treatments, even when the patient is taking the medication as advised, such as using the best technique with inhalers .
A better understanding of this condition has aided the scientific community in discovering new and improved treatments, certainly since I first went to medical school 30 years ago.
We’re better at diagnosing asthma
Historically the diagnosis of asthma has been based on taking a clinical history without performing any objective tests. Over the last couple of years I have been involved in developing the NICE guideline for diagnosing and monitoring asthma.
There is no ‘gold standard’ test to give a definitive diagnosis, which may lead to people having treatments that they do not need, or to a missed diagnosis in people who do have asthma.
Myself and other asthma specialists have recommended objective testing with spirometry and FeNO for most people with suspected asthma.
The FeNO test looks at the levels of nitric oxide in the breath. Increased levels are thought to be related to lung inflammation and asthma. Teams at Royal Brompton have been responsible for research into this diagnostic tool.
The way that we assess people with severe asthma is really important in order to ensure the best possible treatment. Royal Brompton research has pioneered systematic assessment of difficult-to-treat asthma.
Asthma drugs have improved
Our understanding of the causes of asthma and therefore how best to treat the condition has vastly improved over the last 70 years.
There are now combinations of inhaled drugs, which are easy to use and very effective for the vast majority of people with asthma.
Until recently the treatment option for people with severe asthma has been limited to a drug called prednisolone.
Although it can be very effective and lifesaving, there are side-effects, for example, insomnia, weight gain and mood disturbance.
Luckily, there are many more options now, especially in terms of biological agents.
When I became a consultant at Royal Brompton 12 years ago, we started to use Omalizumab, which was a vast improvement for patients with severe allergic asthma.
This medication delivers an antibody that blocks immunoglobulin E and stops allergens from triggering asthma.
We now have biological agents that target the cells (eosinophils) and pathways, which cause the inflammation associated with asthma and they can be transformative for people with severe asthma.
In the future our aim is to never use prednisolone for anyone with severe asthma.
Non pharmacological interventions for severe asthma
Royal Brompton’s Professor Pallav Shah has pioneered bronchial thermoplasty and been involved in research and trials. This procedure involves heating the walls of the airways in a finely controlled way to reduce excess muscle, which can constrict the airways and make it hard to breathe.
Reducing the excess muscle has been shown to reduce the frequency of asthma attacks. This is really good news, as it means patients who are not suitable for a biologic agent have another option for treatment.
The future?
When it comes to asthma, we’re not there yet, there is still plenty to learn and discover. I think the next step, hopefully, within five to ten years will be disease modification.
By this I mean modifying the natural course of the illness to prevent longer term deterioration with drugs that can switch off inflammation for months, even years.
We’re on a journey and there’s great hope for the future.
Dr Andrew Menzies-Gow is a consultant in respiratory medicine and director of the lung division at Royal Brompton Hospital.