title: 'SIMPLES': a structured primary care approach to adults with difficult asthma.
abstract: The substantial majority of patients with asthma can expect minimal breakthrough symptoms on standard doses of inhaled corticosteroids with or without additional add-on therapies. SIMPLES is a structured primary care approach to the review of a person with uncontrolled asthma which encompasses patient education monitoring, lifestyle and pharmacological management and addressing support needs which will achieve control in most patients. The small group of patients presenting with persistent asthma symptoms despite being prescribed high levels of treatment are often referred to as having 'difficult asthma'. Some will have difficult, 'therapy resistant' asthma, some will have psychosocial problems which make it difficult for them to achieve asthma control and some may prove to have an alternative diagnosis driving their symptoms. A few patients will benefit from referral to a 'difficult asthma' clinic. The SIMPLES approach, aligned with close co-operation between primary and specialist care, can identify this patient group, avoid inappropriate escalation of treatment, and streamline clinical assessment and management.
authors: General Practitioner, Woodbrook Medical Centre, Loughborough, UK; Honorary Clinical Research Fellow, Allergy and Respiratory Research Group, The University of Edinburgh, Edinburgh, UK.
authors: Dermot
authors: D
authors: Ryan
authors: Anna
authors: A
authors: Murphy
authors: Björn
authors: B
authors: Ställberg
authors: Noel
authors: N
authors: Baxter
authors: Liam G
authors: LG
authors: Heaney
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000328:Adult; D001249:Asthma / Q000628:therapy*; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D006801:Humans; D010353:Patient Education as Topic; D011320:Primary Health Care / Q000379:methods*; D040242:Risk Reduction Behavior; D012648:Self Care; D016540:Smoking Cessation; D012944:Social Support
chemical_list: D000305:Adrenal Cortex Hormones; D001993:Bronchodilator Agents
references: N Engl J Med. 2012 Sep 27;367(13):1198-207
references: 22938706
references: Respir Med. 2006 Sep;100(9):1479-94
references: 16495040
references: Thorax. 2000 Jul;55(7):566-73
references: 10856316
references: Am J Respir Crit Care Med. 2007 Apr 15;175(8):783-90
references: 17204725
references: Thorax. 2013 Jul;68(7):611-8
references: 23564399
references: Thorax. 2004 Feb;59(2):94-9
references: 14760143
references: BMC Public Health. 2012 Apr 20;12:293
references: 22520046
references: Cochrane Database Syst Rev. 2003;(1):CD001117
references: 12535399
references: Prim Care Respir J. 2009 Jun;18(2):83-8
references: 18698483
references: Respiration. 1998;65(3):195-8
references: 9670301
references: Respir Med. 2012 Jun;106(6):811-9
references: 22357130
references: Respir Med. 2012 May;106(5):635-41
references: 22349066
references: Ir Med J. 1996 Nov-Dec;89(6):226-8
references: 8996955
references: Prim Care Respir J. 2013 Sep;22(3):344-52
references: 23817678
references: Am J Respir Crit Care Med. 2009 Jan 1;179(1):11-8
references: 18948425
references: Arch Bronconeumol. 2011 Apr;47(4):195-203
references: 21459504
references: Eur Respir J. 2003 Sep;22(3):478-83
references: 14516138
references: Allergy. 2004 May;59(5):469-78
references: 15080825
references: Prim Care Respir J. 2013 Mar;22(1):112-6
references: 23412110
references: Respir Med. 2006 Apr;100(4):616-21
references: 16226443
references: J Allergy Clin Immunol. 2004 Jan;113(1):59-65
references: 14713908
references: Ann Allergy Asthma Immunol. 1997 Sep;79(3):177-85; quiz 185-6
references: 9305223
references: Arch Intern Med. 1999 May 10;159(9):941-55
references: 10326936
references: Prim Care Respir J. 2012 Sep;21(3):288-94
references: 22751737
references: Nihon Kokyuki Gakkai Zasshi. 2010 Feb;48(2):99-103
references: 20184238
references: N Engl J Med. 2009 Apr 9;360(15):1487-99
references: 19357404
references: Curr Med Res Opin. 2010 Jul;26(7):1691-6
references: 20465366
references: Thorax. 2006 Aug;61(8):663-70
references: 16877690
references: J Asthma. 2008 Mar;45(2):109-13
references: 18350401
references: Clin Exp Allergy. 2007 May;37(5):794-802
references: 17456228
references: J Asthma. 2010 May;47(4):345-61
references: 20528586
references: BMJ. 2012 Mar 23;344:e1756
references: 22446569
references: J Allergy Clin Immunol. 2013 Mar;131(3):646-57
references: 23380222
references: Eur Respir J. 1999 Nov;14(5):1034-7
references: 10596686
references: N Engl J Med. 2013 Jun 27;368(26):2455-66
references: 23688323
references: Am J Med. 2010 Nov;123(11):1001-6
references: 20870201
references: Eur Respir J. 2007 Jul;30(1):134-55
references: 17601971
references: Expert Rev Respir Med. 2012 Feb;6(1):91-101; quiz 102-3
references: 22283582
references: BMJ. 2001 May 5;322(7294):1098-100
references: 11337441
references: J Aerosol Med Pulm Drug Deliv. 2012 Feb;25(1):16-22
references: 22047451
references: Cochrane Database Syst Rev. 2004;(3):CD001108
references: 15266440
references: Cochrane Database Syst Rev. 2011 May 11;(5):CD006308
references: 21563151
references: Prim Care Respir J. 2010 Mar;19(1):75-83
references: 20119630
references: Chest. 1994 Jan;105(1):111-6
references: 8275720
references: Respir Med. 2011 Jun;105(6):930-8
references: 21367593
references: Chest. 2012 Feb;141(2):286-288
references: 22315109
references: Am J Respir Crit Care Med. 2009 Nov 1;180(9):817-22
references: 19644048
references: J Asthma. 2010 May;47(4):362-6
references: 20528587
references: J Allergy Clin Immunol. 2004 Jul;114(1):40-7
references: 15241342
references: N Engl J Med. 2011 Sep 22;365(12):1088-98
references: 21812663
references: Eur J Clin Invest. 2011 Dec;41(12):1339-52
references: 21615731
references: Cochrane Database Syst Rev. 2008 Apr 16;(2):CD000011
references: 18425859
references: Prim Care Respir J. 2013 Jun;22(2):244-8
references: 23616055
references: Eur Respir J. 2002 Feb;19(2):246-51
references: 11866004
references: Allergy Asthma Clin Immunol. 2013 Mar 06;9(1):8
references: 23510684
references: J Allergy Clin Immunol. 2013 Mar;131(3):763-71
references: 23380218
references: BMJ. 2009 Feb 24;338:b494
references: 19240094
references: Lancet. 2012 Aug 18;380(9842):651-9
references: 22901886
references: Thorax. 2011 Oct;66(10):910-7
references: 21106547
references: Eur Respir J. 2004 Oct;24(4):659-63
references: 15459147
references: Ups J Med Sci. 2012 Mar;117(1):57-66
references: 22200102
references: J Allergy Clin Immunol. 2010 Sep;126(3):466-76
references: 20816182
references: Am J Respir Crit Care Med. 2000 Dec;162(6):2341-51
references: 11112161
references: J Asthma. 2010 Apr;47(3):340-3
references: 20394521
references: Thorax. 2009 May;64 Suppl 1:i1-51
references: 19406863
references: Am J Respir Crit Care Med. 2010 Jan 15;181(2):116-24
references: 19815809
references: N Engl J Med. 2000 Aug 3;343(5):332-6
references: 10922423
references: Prim Care Respir J. 2009 Dec;18(4):243-9
references: 19513494
references: Ann Intern Med. 2009 Jul 21;151(2):110-20
references: 19620163
references: Lancet. 2005 Mar 12-18;365(9463):974-6
references: 15767000
references: Thorax. 2003 Jul;58(7):561-6
references: 12832665
references: Ann Intern Med. 2006 Jun 20;144(12):904-12
references: 16754916
references: Fam Pract. 1989 Sep;6(3):203-9
references: 2792621