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Asthma inhalers have ‘almost become fashion accessory’

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Childhood asthma is being “over-diagnosed” and inhalers are frequently dispensed for no good reason to the point where they have “almost become a fashion accessory”, argue UK respiratory experts.

They claimed that, while asthma was undoubtedly underdiagnosed in the past, the pendulum had now swung too far in the opposite direction.

“The diagnosis of asthma has been trivialised and inhalers dispensed for no good reason”

Professor Bush and Dr Fleming

Professor Andrew Bush, from Royal Brompton and Harefield NHS Foundation Trust, and Dr Louise Fleming, of Imperial College London, issued their warning today in the Archives of Disease in Childhood.

They said the trend was of concern because of the cost of inhalers and their side effects, which are more likely to occur in patients who are prescribed an inappropriate dose.

They noted potential side effects included growth suppression and the dampening down of immune cell activity in the airways and the subsequent heightened risk of respiratory infections.

“There is also evidence that systemic absorption of [inhaled corticosteroids] depends not just on the prescribed dose, but is greater if the dose is inappropriately high for the degree of airway inflammation,” they warned.

Royal Brompton and Harefield NHS Foundation Trust

Claims asthma being ‘over-diagnosed’ in primary care

Andrew Bush

Professor Bush and Dr Fleming highlighted that the key to diagnosing asthma correctly was a detailed knowledge of normal respiratory symptoms in healthy children.

“We propose that one contributing factor is that the diagnosis of asthma has been trivialised and inhalers dispensed for no good reason, and have become almost a fashion accessory,” they said. “The result is, the fact that asthma is a killing disease if not correctly managed, is overlooked.”

The hallmark symptom of asthma – wheeze – was all too often used imprecisely by both parents and healthcare professionals, they said.

They suggested that more objective evidence, such as simple breathing tests, were required before a diagnosis of asthma was made.

“We urgently need… a definitive test to ensure people get the right diagnosis”

Samantha Walker

They questioned whether there was “any other chronic disease in the world in which children are committed to potentially hazardous, long term therapy without every effort being made objectively to document the diagnosis”.

They recommended the need for clinicians to remember that many children outgrow asthma symptoms and that treatment should not simply be stepped up if the child fails to respond.

Dr Samantha Walker, director of research and policy at Asthma UK, said the findings illustrated the “challenges” faced by clinicians due to a lack of “one definitive way of easily diagnosing asthma”.

She described it as “astonishing” that there was still no test a child could be given to tell if they “definitely have asthma”.

“We urgently need more investment in asthma research to get to a definitive test to ensure people get the right diagnosis,” she added.

“The key to improving standards of asthma diagnosis is for repeated careful clinical assessment in primary care”

Duncan Keeley

Dr Duncan Keeley, policy lead at the Primary Care Respiratory Society, said: “The key to improving standards of asthma diagnosis is for repeated careful clinical assessment in primary care – where most asthma diagnoses are made.”

He added that the “key elements” of this process were “careful clinical assessment supported by peak flow monitoring, careful trials of introducing and withdrawing treatment and regular review of the diagnosis, with readiness to refer for specialist assessment when the diagnosis is in doubt”.

Dr Maureen Baker, chair of the Royal College of General Practitioners, also highlighted that diagnosing asthma was “incredibly difficult” in young children, because some common symptoms were similar to those of other illnesses and there was no single definitive test.

“Some diagnostic tests are already available to primary care in the UK,” she said. “New tests that become available will need to be validated for use in children followed by investment in general practice covering relevant equipment and training in the best interests of our patients.”

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