Impacts on Guidelines

GINA 2019

The Global Initiative for Asthma (GINA) is an international organization committed to improving the lives of people with asthma in every corner of the globe.

Our research has had an impact on the way asthma is diagnosed and treated as per the most recent GINA guidelines in 2019. When it comes to asthma diagnosis, there are multiple factors that could make the process difficult – primary care physicians may have insufficient resources to do so, it may be difficult to distinguish between asthma, COPD and asthma-COPD overlap (ACO), etc. Our research has therefore established multiple patient self-administered questionnaires to confirm the diagnosis of asthma1,5,6.

In terms of improving treatment outcomes, we proposed that instead of simply evaluating disease severity in patients, their level of asthma control (as defined by GINA) should be measured via the Asthma Control TestTM. This will paint a clearer picture of how they are responding to their treatment and will also help guide future treatments2. Furthermore, we also highlighted the importance of patient adherence to medication in improving treatment outcomes and suggested a method to improve said adherence4. Lastly, we evaluated the effectiveness of montelukast, a leukotriene receptor antagonist (LTRA), in controlling asthma symptoms and found it to be a viable choice for both adults and children3,7.

The full list of OPRI’s research as cited in GINA’s 2019 guidelines can be found below:

  1. Levy ML, Fletcher M, Price DB, Hausen T, Halbert RJ, Yawn BP. International Primary Care Respiratory Group (IPCRG) Guidelines: diagnosis of respiratory diseases in primary care. Prim Care Respir J 2006; 15:20-34. [PubMed] [Full Text]
  2. Thomas M, Kay S, Pike J, Williams A, Rosenzweig JR, Hillyer EV, Price D. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J 2009; 18:41-9. [PubMed] [Full Text]
  3. Price DB, Hernandez D, Magyar P, Fiterman J, Beeh KM, James IG, Konstantopoulos S, et al. Randomised controlled trial of montelukast plus inhaled budesonide versus double dose inhaled budesonide in adult patients with asthma. Thorax 2003;58:211-6. [PubMed] [Full Text]
  4. Price D, Robertson A, Bullen K, Rand C, Horne R, Staudinger H. Improved adherence with once-daily versus twice-daily dosing of mometasone furoate administered via a dry powder inhaler: a randomized open-label study. BMC Pulm Med 2010;10:1. [PubMed] [Full Text]
  5. Price DB, Tinkelman DG, Halbert RJ, Nordyke RJ, Isonaka S, Nonikov D, Juniper EF, et al. Symptom-based questionnaire for identifying COPD in smokers. Respiration 2006;73:285-95. [PubMed] [Full Text]
  6. Tinkelman DG, Price DB, Nordyke RJ, Halbert RJ, Isonaka S, Nonikov D, Juniper EF, et al. Symptom-based questionnaire for differentiating COPD and asthma. Respiration 2006;73:296-305. [PubMed] [Full Text]
  7. Robertson CF, Price D, Henry R, Mellis C, Glasgow N, Fitzgerald D, Lee AJ, et al. Short-course montelukast for intermittent asthma in children: a randomized controlled trial. Am J Respir Crit Care Med 2007;175:323-9. [PubMed] [Full Text]

GOLD

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) is an international organization aiming to improve the lives of COPD patients all over the world. The GOLD criteria are currently most commonly used to evaluate the severity of COPD in terms of expiratory airflow obstructions.

Our research has had an impact on how COPD is assessed and treated as per GOLD guidelines 2019 and 2020.

As highlighted in the 2019 guidelines, we developed a simple method known as the DOSE Index to assess the severity of COPD1. We also highlighted the risks involved in using inhaled corticosteroids (ICS) to treat COPD2. Lastly, we described the prescription pathways in severe COPD patients that ultimately lead to the prescription of triple therapy, i.e. the use of a long-acting beta agonist (LABA) bronchodilator with a long acting muscarinic antagonist (LAMA) and an inhaled corticosteroid (ICS)3.

The 2020 guidelines reiterated the importance of our research as cited in the 2019 guidelines. They also featured our work which found that the addition of a low dose of theophylline had little impact on exacerbation rates and therefore cannot be recommended as adjunctive therapy to ICS in managing symptoms of COPD5. Finally, our approach to match inhaler devices to patients to minimize handling errors and improve adherence and compliance by asking the four questions: who, what, where and how was outlined6.

The full list of OPRI’s research as cited in GOLD’s 2019 and 2020 guidelines can be found below:

2019:

  1. Jones RC, Donaldson GC, Chavannes NH, Price D, et al. Derivation and validation of a composite index of severity in chronic obstructive pulmonary disease: the DOSE Index. Am J Respir Crit Care Med 2009; 180(12): 1189-95. [PubMed] [Full Text]
  2. Price D, Yawn B, Brusselle G, Rossi A. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. Prim Care Respir J 2013; 22(1): 92-100. [PubMed] [Full Text]
  3. Brusselle G, Price D, Gruffydd-Jones K, et al. The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK. Int J Chron Obstruct Pulmon Dis 2015; 10:2207-17. [PubMed] [Full Text]
2020:
  1. Jones RC, Donaldson GC, Chavannes NH, Kida K, Dickson-Spillmann M, Hardin S, Wedzicha JA, Price D, Hyland ME. Derivation and validation of a composite index of severity in chronic obstructive pulmonary disease: the DOSE Index. Am J Respir Crit Care Med 2009;180(12):1189-1195. [PubMed] [Full Text]
  2. Devereux G, Cotton S, Fielding S, McMeekin N, Barnes PJ, Briggs A, Burns G, Chaudhuri , Chrystyn H, Davies L, De Soyza A, Gompertz S, Haughney J, Innes K, Kaniewska J, Lee A, Morice A, Norrie J, Sullivan A, Wilson A, Price D. Effect of Theophylline as adjunct to inhaled corticosteroids on exacerbations in patients with COPD: a randomized clinical trial. J Amer Med Assoc 2018;320(15):1548-1559. [PubMed] [Full Text]
  3. Dekhuijzen PN, Vincken W, Virchow JC, Roche N, Agusti A, Lavorini F, van Aalderen WM, Price D. Prescription of inhalers in asthma and COPD: towards a rational, rapid and effective approach. Respir Med 2013;107(12):1817-1827. [PubMed] [Full Text]
  4. Price D, Yawn B, Brusselle G, Rossi A. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. Prim Care Respir J 2013; 22(1): 92-100. [PubMed] [Full Text]
  5. Brusselle G, Price D, Gruffydd-Jones K, et al. The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK. Int J Chron Obstruct Pulmon Dis 2015; 10:2207-17. [PubMed] [Full Text]

NICE Guidelines for Asthma 2017

The National Institute for Health and Care Excellence (NICE) is a UK-based organization that aims improves health and social care through evidence-based guidance. OPRI’s research was featured in their most recent guidelines for the management and treatment of asthma.

As highlighted in the guidelines, we found that tele-healthcare interventions were a viable alternative to face-to-face consultations. They also had the added benefit of being shorter and therefore enabling more patients to be reviewed in the same amount of time1.

The full list of OPRI’s research as cited in the NICE guidelines for asthma 2017 can be found below:

  1. Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ. 2003; 326(7387):477-479. [PubMed] [Full Text]

BTS/SIGN 2019

The BTS/SIGN guidelines are developed by the British Thoracic Society (BTS) in conjunction with the Scottish Intercollegiate Guidelines Network (SIGN). Both organizations work towards improving patient care by developing evidence-based guidelines for the National Health Service (NHS) in the UK and Scotland respectively. While SIGN covers a wide variety of diseases, BTS is focused specifically on lung diseases.

Our research has had an impact on how asthma treatment and outcomes can be improved as per the most recent BTS/SIGN 2019 guidelines for the management of asthma. In terms of asthma treatment, we identified the factors associated with an increased risk of exacerbations in adults with asthma1,2. We also evaluated the effectiveness of oral montelukast in reducing asthma symptoms in children and found it to be a viable choice4.

In terms of improving health outcomes, we found that personalized asthma action plans (PAAPs) could improve asthma quality of life questionnaire (AQLQ) scores3. When looking at tele-healthcare methods of monitoring and treating asthma, we found that there was not much clinical benefit to using a mobile app to monitor symptoms. Furthermore, this method was associated with increased costs due to the expenses of telemonitoring5. However, tele-healthcare consultations were found to be a better option than face-to-face consultations as they had the added benefit of enabling more patients to be reviewed in the same amount of time6.

The full list of OPRI’s research as cited in the 2019 BTS/SIGN guidelines for the management of asthma can be found below:

  1. Blakey JD, Price DB, Pizzichini E, Popov TA, Dimitrov BD, Postma DS, et al. Identifying Risk of Future Asthma Attacks Using UK Medical Record Data: A Respiratory Effectiveness Group Initiative. J Allergy Clin Immunol Pract 2017;5(4):1015-24.e8. [PubMed] [Full Text]
  2. Price D, Wilson AM, Chisholm A, Rigazio A, Burden A, Thomas M, et al. Predicting frequent asthma exacerbations using blood eosinophil count and other patient data routinely available in clinical practice. J Asthma Allergy 2016;9:1-12. [PubMed] [Full Text]
  3. Cleland JA, Hall S, Price D, Lee AJ. An exploratory, pragmatic, cluster randomised trial of practice nurse training in the use of asthma action plans. Prim Care Respir J 2007;16(5):311-8. [PubMed] [Full Text]
  4. Robertson CF, Price D, Henry R, Mellis C, Glasgow N, Fitzgerald D, et al. Short-course montelukast for intermittent asthma in children: a randomized controlled trial. Am J Manag Care 2007;175(4):323-9. [PubMed] [Full Text]
  5. Ryan D, Price D, Musgrave SD, Malhotra S, Lee AJ, Ayansina D, et al. Clinical and cost effectiveness of mobile phone supported self monitoring of a.sthma: multicentre randomised controlled trial. BMJ 2012;344:e1756. [PubMed] [Full Text]
  6. Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D, et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. British Medical Journal 2003;326(7387): 477-9. [PubMed] [Full Text]

MTS Clinical Practice Guideline for the Management of Asthma in Adults 2017

The Malaysian Thoracic Society (MTS) is an organization dedicated to improving the knowledge and practice of thoracic and respiratory medicine via the facilitation of research, collaborative work and scientific meetings. They also publish guidelines for the management of asthma and COPD. The most recent clinical practice guideline for the management of asthma in adults was published in 2017, for which Professor David Price was a reviewer.

Results of the CRITIKAL study, a study conducted by OPRI, was featured in this guideline1. The CRITIKAL study examined the association between common errors when handling inhalers and asthma outcomes. While poor inhaler technique is associated with poor asthma outcomes, there is little research on which errors have the greatest impact on outcomes. The CRITIKAL study therefore presented a clearer picture on the actual relationships between specific errors in inhaler handling and asthma outcomes, which was then used by MTS to describe proper inhaler techniques in their guideline for asthma management.

The full list of OPRI’s research as cited in the Malaysian Thoracic Society’s guidelines for the management of asthma can be found below:

  1. Price DB, Roman-Rodriguez M, McQueen RB, et al. Inhaler Errors in the CRITIKAL Study: Type, Frequency, and Association with Asthma Outcomes. J Allergy Clin Immunol Pract 2017;5(4):1071-1081 [PubMed] [Full Text]

COPD-X 2019

The COPD-X Plan is a set of guidelines developed for the management of COPD by the Lung Foundation Australia and The Thoracic Society of Australia and New Zealand. It is updated every quarter, and the most recent update featured some of OPRI’s research as described below.

As highlighted in the COPD-X Plan, COPD patients are often prescribed multiple inhalers as part of their treatment regime. However, alternating between inhalers that require different inhalation techniques can lead to poor technique, and thereby, poor outcomes. Therefore, it is recommended that the number of different inhaler devices prescribed to COPD patients be reduced1.

In terms of add-on treatment to reduce exacerbation rates, a low dose of theophylline in combination with standard ICS treatment was investigated. Results showed no impact on exacerbation rates and therefore, theophylline is not recommended as adjunctive therapy to ICS2.

On the other hand, β-blockers were found to be underused in the treatment of COPD with comorbid heart failure (HF). HF is a common comorbidity of COPD and is often treated with β-blockers, which is also recommended by guidelines for the treatment of COPD across all severities. However, it is rarely prescribed due to concerns about bronchoconstriction and its effect on other common comorbidities such as diabetes and renal impairment. While more research is required to determine the risk-benefit ratio of prescribing β-blockers for COPD patients, preliminary results for the management of COPD-HF are promising3.

The full list of OPRI’s research as cited in the COPD-X guidelines can be found below:

  1. Bosnic-Anticevich S, Chrystyn H, Costello RW, Dolovich MB, Fletcher MJ, Lavorini F, Rodriguez-Roisin R, Ryan D, Wan Yau Ming S, Price DB. The use of multiple respiratory inhalers requiring different inhalation techniques has an adverse effect on COPD outcomes. Int J Chron Obstruc Pulmon Dis 2016;12:59-71. [PubMed] [Full Text]
  2. Devereux G, Cotton S, Fielding S, McMeekin N, Barnes PJ, Briffs A, Burns G, Chaudhuri R, Chrystyn H, Davies L, De Soyza A, Gompertz S, Haughney J, Innes K, Kaniewska J, Lee A, Morice A, Norrie J, Sullivan A, Wilson A, Price D. Effect of Theophylline as adjunct to inhaled corticosteroids on exacerbations in patients with COPD: a randomized clinical trial. JAMA 2018;320:1548-1559. [PubMed] [Full Text]
  3. Lipworth B, Skinner D, Devereux G, Thomas V, Ling Zhi Jie J, Martin J, Carter V, Price DB. Underuse of beta-blockers in heart failure and chronic obstructive pulmonary disease. Heart 2016;102:1909-1914. [PubMed] [Full Text]