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‘Major change of practice’ in asthma advice

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New guidance in the Australian Asthma Handbook advises against prescribing or recommending treatment using only short-acting beta2 agonists (SABA) to manage the condition in adults and adolescents.
 
It signals a move away from the so-called blue puffers that have long been a feature of asthma treatment.
 
The advice is contained in the updated guidelines in the National Asthma Council (NAC) handbook, launched by Federal Health and Ageing Minister Mark Butler at a webinar for health professionals on Tuesday.
 
Inhaled corticosteroids (ICS) are now indicated for all adults and adolescents with asthma.

Professor Nick Zwar, Chair of the NAC Guidelines Committee, said the most significant change in the handbook is due to a shift in evidence about the use of SABA.
 
‘Research over the last few years and randomised trials has shown that it has its risks, that people who do use that alone for their asthma are more at risk of exacerbations – which are sometimes severe – and that their asthma control is sometimes suboptimal,’ he told newsGP.
 
‘The recommendation now is that people should be using a reliever that contains a low-dose corticosteroid.
 
‘This is sometimes called AIR therapy, anti-inflammatory reliever, it’s got a corticosteroid and a beta-agonist as well in the same puffer or in the same device.’
 
Professor Zwar, a Queensland GP, said that asthma patients going to the pharmacist to get their blue puffers are likely to be told to go to their doctor to get a prescription for the anti-inflammatory reliever.
 
‘That’s a major change in practice,’ he said.
 
According to Professor Zwar, another significant change means maintenance-and-reliever therapy (MART) is now the preferred pathway when patients step up to using a medicine every day for asthma.
 
‘In the past, we’ve said that pathway is equally recommended with using inhaled corticosteroid low-dose every day, plus a short-acting beta agonist, in two separate puffers typically,’ he said.
 
‘That pathway remains available and some people are very well controlled on that – and you may not see any reason to change them.
 
‘But the maintenance reliever with that same puffer is now the preferred next step up in the approach to asthma therapy.’
 
In its launch of the updated handbook, the NAC summarised the key changes as follows:
 
Initial treatment for most patients

• Treatment in adults and adolescents should be started with inhaled low-dose budesonide-formoterol (AIR-only therapy), taken as needed when symptoms occur.
• Low-dose budesonide-formoterol as needed reduces the risk of severe exacerbations requiring oral corticosteroids, compared with SABA taken as needed.
• The older treatment, maintenance treatment with low-dose ICS (plus salbutamol as needed) is the alternative treatment option for patients with a new diagnosis of asthma.
• Maintenance treatment is generally not necessary for adults and adolescents with infrequent symptoms and no specific indications for maintenance ICS treatment.
• For patients using maintenance low-dose ICS plus SABA as needed (alternative Level 1 option), consider switching to budesonide-formoterol as needed (recommended Level 1 treatment) as a strategy to reduce exacerbation risk.

MART (maintenance-and-reliever therapy)

• Start treatment at a higher level (low-dose MART or medium-dose MART) if the patient has frequent symptoms, a recent severe asthma exacerbation that required treatment with systemic corticosteroids, or known risk factors for severe exacerbations.
• MART reduces the rate of exacerbations, compared with fixed-dose maintenance ICS-LABA regimens (with SABA as needed) at the same or a higher ICS dose.
• Low-dose MART using budesonide-formoterol can easily be stepped down to as-needed budesonide-formoterol, without the need for a new inhaler.
• For patients using maintenance ICS-LABA plus SABA as needed, consider switching to MART before considering a dose increase.
• The older treatment, maintenance treatment with low-dose ICS (plus salbutamol as needed) is the alternative treatment option for patients with a new diagnosis of asthma.

The handbook highlights the importance of a written asthma plan for every patient prescribed AIR or MART treatment.
 
Professor Zwar also drew attention to an altered threshold for referring patients with difficult-to-control asthma to a specialist respiratory physician, given the advent of new biologic therapies.
 
‘That’s another step further up and for fewer people, but those medicines can be very effective for people with severe asthma,’ he said.
 
‘We’re trying to avoid large doses of inhaled corticosteroid and particularly trying to avoid recurrent courses of oral steroids.
 
‘The evidence on the risks of oral steroids for bone health and other adverse effects has become clearer and we really want to be trying to minimise the number of times people need a course of oral steroids.’
 
For diagnosis, Professor Zwar noted the importance of spirometry, but said rates of spirometry in primary care have dropped since the COVID-19 pandemic due to concerns about infection control.
 
He said the handbook also includes advice on referrals for the fractional exhaled nitric oxide (FENO) test to differentiate asthma from other conditions.
 
‘About one in 10 Australians have asthma and there are about 56,600 emergency department visits each year for asthma,’ Professor Zwar said.
 
‘When I was a young GP, we seemed to see asthma all the time and that’s not quite the case anymore, but it’s still common and there’s significant morbidity and sometimes mortality related to asthma.
 
‘We’d like to prevent all asthma deaths if we possibly could and we’d like to reduce the burden of asthma in terms of symptoms that better asthma control can improve.’
 
The updated Australian Asthma Handbook published by the National Asthma Council is now available online.
 
A recording of the launch webinar, which is CPD-approved, is also now available.

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