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      Bringing asthma care into the twenty-first century

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          Abstract

          Despite access to diagnostic tests and effective therapies, asthma often remains misdiagnosed and/or poorly controlled or uncontrolled. In this review, we address the key issues of asthma diagnosis and management, recent evidence for levels of asthma control, the consequences of poor control and, in line with that, explore the potential reasons for poor asthma control and acute exacerbations. Based on recent evidence and current guidelines, we also aim to provide practical answers to the key questions of how to improve asthma management, with the best possible prevention of exacerbations, addressing the basics—adherence, inhaler misuse, obesity and smoking—and how to facilitate a new era of asthma care in the twenty-first century. We hope this review will be useful to busy primary care clinicians in their future interactions with their patients with both suspected and proven asthma.

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          Most cited references95

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          Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study.

          For most patients, asthma is not controlled as defined by guidelines; whether this is achievable has not been prospectively studied. A 1-year, randomized, stratified, double-blind, parallel-group study of 3,421 patients with uncontrolled asthma compared fluticasone propionate and salmeterol/fluticasone in achieving two rigorous, composite, guideline-based measures of control: totally and well-controlled asthma. Treatment was stepped-up until total control was achieved (or maximum 500 microg corticosteroid twice a day). Significantly more patients in each stratum (previously corticosteroid-free, low- and moderate-dose corticosteroid users) achieved control with salmeterol/fluticasone than fluticasone. Total control was achieved across all strata: 520 (31%) versus 326 (19%) patients after dose escalation (p < 0.001) and 690 (41%) versus 468 (28%) at 1 year for salmeterol/fluticasone and fluticasone, respectively. Asthma became well controlled in 1,071 (63%) versus 846 (50%) after dose escalation (p < 0.001) and 1,204 (71%) versus 988 (59%) at 1 year. Control was achieved more rapidly and at a lower corticosteroid dose with salmeterol/fluticasone versus fluticasone. Across all strata, 68% and 76% of the patients receiving salmeterol/fluticasone and fluticasone, respectively, were on the highest dose at the end of treatment. Exacerbation rates (0.07-0.27 per patient per year) and improvement in health status were significantly better with salmeterol/fluticasone. This study confirms that the goal of guideline-derived asthma control was achieved in a majority of the patients.
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            Inhaled Combined Budesonide–Formoterol as Needed in Mild Asthma

            In patients with mild asthma, as-needed use of an inhaled glucocorticoid plus a fast-acting β2-agonist may be an alternative to conventional treatment strategies.
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              Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study.

              Asthma management guidelines provide recommendations for the optimum control of asthma. This survey assessed the current levels of asthma control as reported by patients, which partly reflect the extent to which guideline recommendations are implemented. Current asthma patients were identified by telephone by screening 73,880 households in seven European countries. Designated respondents were interviewed on healthcare utilization, symptom severity, activity limitations and asthma control. Current asthma patients were identified in 3,488 households, and 2,803 patients (80.4%) completed the survey. Forty-six per cent of patients reported daytime symptoms and 30% reported asthma-related sleep disturbances, at least once a week. In the past 12 months, 25% of patients reported an unscheduled urgent care visit, 10% reported one or more emergency room visits and 7% reported overnight hospitalization due to asthma. In the past 4 weeks, more patients had used prescription quick-relief medication (63%) than inhaled corticosteroids (23%). Patient perception of asthma control did not match their symptom severity; approximately 50% of patients reporting severe persistent symptoms also considered their asthma to be completely or well controlled. The current level of asthma control in Europe falls far short of the goals for long-term asthma management. Patients' perception of asthma control is different from their actual asthma control.
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                Author and article information

                Contributors
                kjell.larsson@ki.se
                Journal
                NPJ Prim Care Respir Med
                NPJ Prim Care Respir Med
                NPJ Primary Care Respiratory Medicine
                Nature Publishing Group UK (London )
                2055-1010
                5 June 2020
                5 June 2020
                2020
                : 30
                : 25
                Affiliations
                [1 ]ISNI 0000 0004 1937 0626, GRID grid.4714.6, Integrative Toxicology, National Institute of Environmental Medicine, IMM, , Karolinska Institute, ; Stockholm, Sweden
                [2 ]ISNI 0000 0004 0391 502X, GRID grid.415465.7, Department of Respiratory Medicine, , Seinäjoki Central Hospital, ; Seinäjoki, Finland
                [3 ]ISNI 0000 0001 2314 6254, GRID grid.502801.e, Faculty of Medicine and Health Technology, , University of Tampere, ; Tampere, Finland
                [4 ]ISNI 0000 0004 1936 9457, GRID grid.8993.b, Department of Medical Sciences: Respiratory, Allergy and Sleep Research, , Uppsala University, ; Uppsala, Sweden
                [5 ]ISNI 0000 0004 0628 2985, GRID grid.412330.7, Allergy Centre, , Tampere University Hospital, ; Tampere, Finland
                [6 ]ISNI 0000 0004 1936 9457, GRID grid.8993.b, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, , Uppsala University, ; Uppsala, Sweden
                [7 ]Department of Medicine, Little Belt Hospital, Vejle, Denmark
                [8 ]Tananger Medical Center, Tananger, Norway
                [9 ]Aarup Doctors Medical Centre, Aarup, Denmark
                [10 ]ISNI 0000 0004 0646 8202, GRID grid.411905.8, Respiratory Research Unit Hvidovre, Department of Respiratory Medicine, , Copenhagen University Hospital Hvidovre, ; Hvidovre, Denmark
                [11 ]ISNI 0000 0001 0674 042X, GRID grid.5254.6, Institute of Clinical Medicine, , University of Copenhagen, ; Copenhagen, Denmark
                Author information
                http://orcid.org/0000-0001-5258-0906
                http://orcid.org/0000-0003-1586-4998
                http://orcid.org/0000-0002-6905-4141
                Article
                182
                10.1038/s41533-020-0182-2
                7275071
                32503985
                aa91e36e-2cc7-4ceb-ad0f-fb8a70d06011
                © The Author(s) 2020

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 14 February 2020
                : 21 April 2020
                Funding
                Funded by: FundRef https://doi.org/10.13039/100004325, AstraZeneca;
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                Categories
                Review Article
                Custom metadata
                © The Author(s) 2020

                patient education,disease prevention
                patient education, disease prevention

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