Asthma guidelines: recommendations versus reality.

Highly effective treatments for asthma are now available, but many patients with asthma are still poorly controlled. Guidelines for asthma therapy are widely disseminated, but they may be considered too complex for general use, and clinical studies used to support the guidelines are not indicative of 'real life'. In the 'real' world, patients frequently cannot use their inhaler correctly, particularly pressurised metered-dose inhalers (pMDIs) which require good coordination between inhaler activation and patient inhalation. Breath-activated inhalers and dry powder inhalers (DPIs) are much easier to use and result in better lung deposition of the inhaled drug. Surprisingly, two recent Cochrane meta-analyses recommended that pMDIs should be preferentially prescribed, as they have similar efficacy to breath-activated inhalers and DPIs and are cheaper. In reality, DPIs are more cost-effective as they deposit more drug in the lungs, may improve compliance and result in more effective asthma control. Improvements in inhaled drug delivery will continue to be paramount in improving asthma management.