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Asthma

Precision Medicine

The MRINZ is part of an international collaborative group which has proposed a paradigm shift in the approach to the management of asthma and COPD. It is based on the concept that asthma and COPD represent a continuum of different diseases that share biological mechanisms and present with distinct clinical, pathophysiological and psychosocial features that can be observed and which require individualised treatment. This allows treatments to be targeted to the needs of individual patients on the basis of such clinical characteristics that distinguish a given patient from other patients. The main publication in this field this year has been ‘The Lancet Commission on Asthma’, a major treatise which challenges the current management approach to asthma, and proposes a revolution in thinking about asthma.

Comment: Recommendations made in The Lancet Commission on asthma have the potential to lead to a paradigm shift in the assessment and management of asthma worldwide.


Treatment of mild asthma

In New Zealand about 20% of adults have asthma, of whom 60% have mild disease. Guideline based treatment of mild asthma is regular inhaled corticosteroids (ICS), with a short-acting beta agonist (SABA) as a separate inhaler used when needed for symptom relief. The benefits of regular ICS use are limited in actual clinical practice by poor ICS adherence and low prescription rates. The MRINZ is coordinating two large 12 month randomised controlled trials of patients with mild asthma to determine if a novel regimen of a combination ICS/fast onset long-acting beta agonist inhaler taken as required for relief of symptoms is superior to regular ICS therapy with SABA as required. Both of these studies, Novel START, which is being undertaken in sites in the United Kingdom, Italy, Australia and New Zealand, and PRACTICAL, which is being undertaken in multiple sites in New Zealand have now completed recruitment, and as a result, the findings will be available next year.

Comment: These studies have the potential to change practice in New Zealand and internationally and to improve outcomes in patients with mild asthma who have a poorly recognised yet important burden of disease.


Prevention of asthma

Paediatric asthma is a major public health problem in New Zealand. Prevalence rates for asthma, and for severe asthma, are amongst the highest in the world. There is an urgent need for research that leads to evidenced based primary prevention strategies to reduce the prevalence of asthma. This has led to consideration of the role of novel risk factors that may increase the susceptibility to the development of asthma, and may be amenable to simple public health intervention programmes. One such risk factor for which there is substantive evidence for a potential role in the pathogenesis of asthma is the use of paracetamol. The first ever randomised controlled trial investigating whether paracetamol increases the risk of childhood asthma is about to begin. This study, led by Professor Stuart Dalziel from the University of Auckland, in collaboration with the MRINZ, is funded by the Health Research Council of New Zealand.

Comment: This study not only has the potential to determine whether increasing use of paracetamol over recent decades has contributed to the higher asthma rates, but also could lead to primary intervention strategies.