Health CommitteeWritten evidence from the British Society for Allergy & Clinical Immunology (LTC 85)
We have only recently become aware of this call for evidence. Obesity is an increasing epidemic and is a major issue for respiratory conditions, both in terms of making it difficult for people with respiratory conditions to move about (due to the increased work of breathing and their lack of respiratory reserve, and also through the specific conditions of obesity hypoventilation and obstructive sleep apnoea, both of which lead to hypoxia, hypercarbia (excess CO2), pulmonary hypertension and eventually to right heart failure.
In addition, obesity is an issue in relation to difficult asthma. Beyond the general call for strategies to reduce obesity at the community level, we need better recognition of the role of obesity in making asthma difficult to control—steroids are not the answer in these patients, many of whom have asthma, and are breathless but not due to airways inflammation. Pre-constriction of their airways plays a large part in rendering them wheezy, and they are at high risk of steroid complications if this is not recognised and they are treated (by guidelines) like asthmatics with normal BMI. Education of primary care teams is important, but most of these patients do require specialist support from expert teams (and many secondary care respiratory physicians and A&E doctors are not fully aware of the issues either).
Asthma is an important chronic condition—much of it is mild and can be managed in the community—this has been a major objective for respiratory physicians and allergists since the late 1980s when the first national guidelines for asthma were produced. A significant minority have more severe disease, which either requires large doses of standard therapy or fails to respond to standard therapy. Many of these end up on medium to long term oral steroid therapy.
Within the hospital sector we continue to see those patients whose asthma is difficult to control, either because it is exceptionally severe or because adherence to therapy is poor. And of course we get to see those who have a diagnosis of asthma but do not actually have asthma or those who have more than just asthma—these make up quite a large proportion of those with “difficult asthma” in fact, and the reason they don’t get better with standard anti-asthma drugs is because they don’t have asthma or at least there is more to their symptomatology than just asthma. Failure to recognise this leads to poor control AND to excessive side-effects from over-reliance on oral steroids to control symptom flares.
Better management of these patients requires recognition of the problem by primary and secondary care physicians, and an acknowledgement that this goes beyond the expertise of most secondary chest physicians (although they do not always realise this). Within the specialist services commissioning framework there are plans for a network of tertiary centres whose primary function is to review these patients, separate the wheat from the chaff and get them into appropriate management pathways. While the allergy community feels the number of centres needed to do this should be larger than the number envisaged in the original proposal from the CRG, we accept the general principle that these patients require multidisciplinary assessment by expert teams and should not be managed in conventional general chest clinics.
Turning to the definition of Chronic Long-Term Conditions, I am not clear whether allergic conditions are regarded as CLTCs for the purposes of this inquiry. The call definition says “those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with a LTC is forever altered—there is no return to “normal.”
On this basis, most non-acute medical conditions would fall into consideration. Chronic eczema would definitely fit in; chronic asthma has been discussed above; maybe chronic rhinosinusitis and perhaps seasonal allergic rhinitis should be included, as in most cases they cannot be cured, but they can be contained, either by drug therapy or by specific desensitisation.
Food allergy is intermittent in its presentation, but it has a long term impact on patients and their families, adversely affecting their quality of life.
In view of the very short time-line for submitting evidence, I hope these thoughts are useful. I and my colleagues within the British Society for Allergy & Clinical Immunology would be pleased to expand on anything within this letter.
15 May 2013