An Investigator’s Diary: Bringing asthma care into the 21st century

In the 21st century, total asthma control should be the goal for our patients. That is, our patients should live life as though they don’t have asthma. If the diagnosis is correct, the appropriate medication has been prescribed, and the patient has been provided with (and understands) the necessary instructions, we should be able to send our patients away to enjoy a new, symptom-free life.

After all, have we ever had it so good? The last decade has heralded an improved understanding of the pathophysiology and overall management of asthma. New classes of effective medications have granted us an unprecedented level of freedom in how we manage our patients. Complementing this are regularly updated, comprehensive Canadian Asthma Consensus Guidelines. Surely, asthma symptoms in Canada should be a rare occurrence?

Yet, for the more than three million people living with the disease, they are not. Unfortunately, research reveals the stubborn truth – that sub-optimal asthma management is the norm and not the exception and patients, therefore, live with asthma symptoms as though they are to be expected. In fact, in Canada more than 500 people die and 150,000 visit an emergency room due to asthma each year. A recent national physician self-audit of 6,482 people with asthma revealed that 43 per cent of patients were uncontrolled according to current guidelines. Although recommended in the Canadian Asthma Consensus Guidelines, 39 per cent of patients had not been evaluated using spirometry, 28 per cent reported never having their inhaler technique assessed by a healthcare professional and 80 per cent had no written action plan. Concerningly, almost half of patients surveyed did not follow their physician’s dosing instructions.

However, the poor levels of asthma control in Canada cannot be attributed solely to a disparity between perception and reality, as the problem may also lie in the education and communication between physicians and patients. If physicians and patients do not believe or expect to achieve total control, they are not striving to achieve it.

For many asthma study investigators, myself included, that is what motivated participation in the international Gaining Optimal Asthma Control (GOAL) study. GOAL will be the first study to measure the multiple factors that indicate “total control” of asthma and is expected to set a new standard for acceptable asthma care around the world. The hypothesis is that total control, as defined by international guidelines – such as the Global Initiative for Asthma (GINA) – is a realistic and achievable goal of asthma treatment. The definition of total control used in the trial is the most rigorous used in any asthma trial to date and was the first one that tested to see whether the standards for asthma control were truly achievable.

GOAL was a one-year, randomized, double-blind, parallel group study of patients with uncontrolled asthma that compared a combination medication with an inhaled corticosteroid in achieving two guideline-based measures of control. It followed 3,421 patients from 44 countries around the world, including 16 Canadian sites, to gauge levels of asthma control, ways to improve treatment and, above all else, ways to better the overall quality of life for asthma patients.

Total control was defined as the complete and continuous absence of asthma symptoms with no daytime symptoms, no night-time waking, no activity limitations, no sudden worsenings of the disease requiring hospitalization or ER visits, and no use of ‘rescue’ medications for a minimum assessment period of seven out of eight weeks. To be categorized as having total control, patients were completely and continuously free of all asthma symptoms.

GOAL results are expected in late 2004 and the ‘total control’ approach should encourage more open discussion between patients and physicians about what treatment options will help them achieve better control of their asthma.

Physicians need a reliable, sensitive and accurate measure to identify patients who are not achieving ‘total control’. The GOAL study will propose new standards of care for assessing and achieving true asthma control – the ultimate goal for all Canadians living with asthma.