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inhaler2April 13 2016

Doctors are overdiagnosing asthma in children and prescribing inhalers too readily, an article in The Archives of Disease in Childhood is warning.

Children are still dying because of failures in basic asthma management with one contributing factor being that “the diagnosis of asthma has been trivialised and inhalers dispensed for no good reason, and have become almost a fashion accessory,” say the authors. “The result is the fact that asthma is a killing disease, if not correctly managed, is overlooked.”

The comments are made in a leading article by Professor Andrew Bush, Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, and Dr Louise Fleming, a Clinical Senior Lecturer in Respiratory Paediatrics at the National Heart and Lung Institute.

They give a number of additional reasons as to why asthma overdiagnosis matters, including the cost of asthma medications, and the side effects of inhaled corticosteroids (ICS) such as adrenal suppression and growth failure, and the increased risk of mucosal immunosuppression and respiratory infections. “There is also evidence that systemic absorption of ICS depends not just on the prescribed dose, but is greater if the dose is inappropriately high for the degree of airway inflammation.”

The article highlights the consultation put out by NICE recommending that clinicians should seek more objective evidence before making an asthma diagnosis. “Disappointingly, the idea that asthma may be overdiagnosed and objective tests should be performed has not been uniformly welcomed,” say the authors.

They recognise that recommendations around diagnosis must be practical, and say two principles should apply as a minimum:

  • clinicians must seek evidence of variable airflow obstruction, at least in school-age children, before contemplating an asthma diagnosis;
  • if therapeutic trials of treatment are to be performed, then they should be focused, and children should not be left on an unproven treatment ad infinitum.

Commenting in the article, Dr Samantha Walker, Director of Research and Policy at Asthma UK, has said the findings illustrate the challenges that GP’s face every day because there currently isn’t a definitive way of easily diagnosing asthma. “It’s astonishing in the 21st century that there isn’t a test your child can take to tell if they definitely have asthma.”

As asthma has many different causes and triggers and symptoms can change over a short or long period of time, “this complexity means that it is both over and underdiagnosed, in children and in adults, so people don’t get the care they need to manage their asthma effectively. As a result, a child is admitted to hospital every 20 minutes because of an asthma attack and asthma attacks still kill the equivalent of a classroom of children every year in the UK,” she said.

Links:

BMJ announcement

A Bush and L Fleming. ‘Is asthma overdiagnosed?’. Arch Dis Child. Published online April 5 2016

Asthma UK comment

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